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S SIGNATURE REQUIRED 50B. DATE SIGNED SECTION XII WITNESSES TO SIGNATURE COMPLETE ONLY IF CLAIMANT SIGNED ITEM 50A WITH AN X 51A. Only report payments to the in-home attendant for health care services or assistance with ADLs provided by the health care provider as medical expenses in Items 45A thru 45F. Payments for assistance with IADLs do not qualify as medical expenses. If No skip to Section X 45A. WHOSE MEDICAL LEGAL OR OTHER EXPENSES WERE PAID 45B. PAID TO Name of provider insurance...
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