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I have fulfilled my duty to advise the appellant of the consequences of the withdrawal of the request for hearing and subsequent dismissal. Representative s Signature PRIVACY ACT STATEMENT The legal authority for the collection of information on this form is authorized by the Social Security Act section 1155 of Title XI and sections 1852 g 5 1860D-4 h 1 1869 h I and 1876 of Title XVIII. DEPARTMENT OF HEALTH AND...
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