Long, Randi J. - Pruco Life Policy #V2 583 539

6. Give complete details of any “Yes” answers for questions 1-5, including: Question number, diagnosis, date of onset and recovery, medication/treatment prescribed and the name, address and telephone number of all attending physicians and hospitals. Date of Date of Medication/ Physician/Hospital Question # Diagnosis Onset Recovery Treatment Prescribed Name, Address & Phone Number 1C. BREAST CANCER, 15 YEARS AGO, TREATED WITH CHEMOTHERAPY AND MASTECTOMY; LAST ONCOLOGY VISIT 8/18 WITH BONE SCAN COMPLETED SHOWING SLIGHTLY ELEVATED ALK PHOS; TAMOXIFEN 10 YEARS AGO; BILATERAL OOPHORECTOMY WITH BENIGN RESULTS; HYSTERECTOMY 15 TO 20 YRS AGO: COMPLETE RECOVERY; 1I. BARRETT'S ESOPHAGUS HISTORY AS PROVIDED BY DR. BRADLEY SABIN

REV 2018

ORD 96200-2010

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