A-504 Extended Health Benefits Claim Form

Record of Appointment(s)

To be completed and returned to the Extended Health Benefits section of the Dept of Health

RECORD OF APPOINTMENT (s) to be signed by attending physician or designate or community health nurse.

Physician/Community Nurse Name

Physician/Community Nurse Name	Date	Signature
Physician/Community Nurse Name	Date	Signature Sign above
Physician/Community Nurse Name	Date	Signature Sign above
Physician/Community Nurse Name	Date	Signature Sign above
Physician/Community Nurse Name	Date	Signature Sign above
Physician/Community Nurse Name	Date	Signature Sign above
Physician/Community Nurse Name	Date	Signature Sign above

Steps