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Page 1: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of
Page 2: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of
Page 3: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of
Page 4: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of
Page 5: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of
Page 6: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of
Page 7: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of
Page 8: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of
Page 9: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of
Page 10: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of
Page 11: Vortala · Head Injuries Broken Bones Dislocations Surgeries vqedications Date Allergies itamins/Herbs/ Minerals . AFFIDAVIT Patient's statement "Documenting" Medical Necessity of

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