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Please use the form below to submit your request for Disability Form completion for your pending or previous Thoracic Surgery at UCLA Health.
Patient Name
Email address to have completed form sent to you:
EDD Receipt Number
Enter your physician name (Dr. Jay Lee, Dr. Robert Cameron, Dr. Jane Yanagawa, Dr. Paul Toste or Dr. Sha'Shonda Revels)
Questions/Comments
Please upload your disability form here:
Drop files or click here to upload
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