Dr Statement DM2 by HC120504082116

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									Diabetes Herbicide Presumption                                         C File/SSN:_________________________________
                                                                                    999-99-9999

Physicians Statement                                                                       JOE BLOW
            Veteran:___________________________________




_____________________________________________
Physician’s Printed Name



_____________________________________________               ____________________________________________
Physician’s Signature                                Date   Physician’s Address & Phone Number
               Montgomery County Veterans Service Organization
                          350 Pageant Lane, Suite 308 Clarksville, TN 37040
                           Phone (931) 553-5173/5174 Fax (931) 553-5176




                                                                              October 28, 2008



JAMES HEMBREE
4321 NICE DRIVE
CLARKSVILLE, TN 37042


MR. HEMBREE,

PLEASE PUT YOUR FULL SSN# ON THE ATTACHED COORESPONDENCE AND
HAND CARRY TO YOUR DOCTOR FOR COMPLETION. YOUR PHYSICIAN’S OFFICE
(OR YOU) MAY RETURN THE COMPLETED DOCUMENT TO MY OFFICE (ADDRESS
IS INDICATED ABOVE) AS SOON AS POSSIBLE. AS WE DISCUSSED AT YOUR
APPOINTMENT, THIS INFORMATION WILL BE USED IN SUPPORT OF YOUR
CLAIM. THANK YOU & HAVE A GREAT DAY!


                        KELLI MESEBERG, VSO
                        (931) 553-5173/5174

								
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