div class=trans-pagebutton class=gotoPage data-page=1Page 1button div class=trans-imagea href=https:reader042fdocumentsusreader042viewer20220215165b1d101b7f8b9a0b2c8ba7c2html5page1jpg target=_blank img data-url=document2-3-4-5-6-medical-charges-reimbursement-formpdf-medical-charges-reimbursementhtmlpage=1 data-page=1 class=trans-thumb lazyload alt=Page 1: 2 3 4 5 6 MEDICAL CHARGES REIMBURSEMENT … Formpdf · MEDICAL CHARGES REIMBURSEMENT Name of Patient relation with the Claimant Period of Illness HPTR FORM 6 that loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAQAAAC1HAwCAAAAC0lEQVR42mM8Uw8AAh0BTZud3BwAAAAASUVORK5CYII= data-src=https:reader042fdocumentsusreader042viewer20220215165b1d101b7f8b9a0b2c8ba7c2html5thumbnails1jpg width=140 height=200 adivdivdiv class=trans-pagebutton class=gotoPage data-page=2Page 2button div class=trans-imagea href=https:reader042fdocumentsusreader042viewer20220215165b1d101b7f8b9a0b2c8ba7c2html5page2jpg target=_blank img data-url=document2-3-4-5-6-medical-charges-reimbursement-formpdf-medical-charges-reimbursementhtmlpage=2 data-page=2 class=trans-thumb lazyload alt=Page 2: 2 3 4 5 6 MEDICAL CHARGES REIMBURSEMENT … Formpdf · MEDICAL CHARGES REIMBURSEMENT Name of Patient relation with the Claimant Period of Illness HPTR FORM 6 that loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAQAAAC1HAwCAAAAC0lEQVR42mM8Uw8AAh0BTZud3BwAAAAASUVORK5CYII= data-src=https:reader042fdocumentsusreader042viewer20220215165b1d101b7f8b9a0b2c8ba7c2html5thumbnails2jpg width=140 height=200 adivdiv