Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility Page 3

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ADDITIONAL QUESTIONS FOR THE TREATING HEALTH CARE PROFESSIONAL TO ANSWER: (These questions
may be answered here or you may attach documents. Remember to sign and date this form.)
ADDITIONAL COMMENTS BY THE TREATING HEALTH CARE PROFESSIONAL: (Any additional
information may be provided here or you may attach documents. Remember to sign and date this form.)
CERTIFICATION IS REQUIRED. I hereby with full knowledge of the penalty of fine and / or imprisonment, as provided in §943.39 of the
Wisconsin Statutes, that this report, together with any attached documents, truly and correctly sets forth the claimant’s history, my findings,
diagnosis and opinion.
Signature of Health Care Professional: _____________________________________________________________________________
Printed Name: _________________________________________________________________________________________________
Title _________________________________________________________________________________________________________
Phone number: (_______)____________________
Date: ______________________________________
UCB-474ho (R. 10/99)
3.29
April 2000

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