MEDICAL REIMBURSEMENT CLAIM FORM (To be filled up by the Principal Card holder in BLOCK LETIERS) 1. Box 31370 • Tampa, FL 33631 Use this claim form to be reimbursed for eligible out-of-pocket medical expenses. @kundar1985. Pulipaka_ramarao. Form OWCP-915 can be used to seek reimbursement for expenses in regard to medical treatment, prescription medication and medical supplies. FORM -MRC (S) (For serving employees) CENTRAL GOVERNMENT HEALTH SCHEME MEDICAL REIMBURSEMENT CLAIM FORM (To be filled up by the Principal Card holder in BLOCK LETIERS) 1. A reimbursement form needs to add different details in its frame to get the attention of the insurance companies. Name of the Patient: 7. Total expense 100,000 rupees are incurred. But for receiving that help the employee or anyone on behalf of him or her needs to fill up a form and need to process it. This medical bill reimbursement form can be shared anywhere online. 2Attachyour itemized statement (or fully legible copyof the bill) to the back of this form. A medical reimbursement form is designed and filled up to get the money reimbursed which they have spent for some medical issues. Medical Reimbursement software & Proposal forms for AP/ Telangana Teachers / Employees 2020. Treasury Employee Code : _____ 3. To, MCB Bank Ltd Human Resource, Medical Department Karachi. A proper form structure would be able to help you to support them and by supporting building a better bond. are to be filled in the medical advance bill form. The time limit for filing claims is one year from the date of service/purchase. The medical reimbursement forms should begin by asking the details of the employee. Salary (Basic Pay + D.A)/Pension (as on 1.04.04): 5. _____ Dated: _____. Framing proper medical reimbursement form might be a time-consuming process, as you need to focus on the different medical requirements. You should ask to provide different documents for giving medical reimbursement. User Manual of Citizen Login for Payment of Medical Reimbursement of Medical Health and Family Welfare Department, Uttar Pradesh Version 1.0 Page 10 of 12 a. Proper space should be provided so that its summed up amount can be added to the reimbursement sheet. This is a simple reimbursement structure that can help you to structure your requirements specifically. Medical Reimbursement Proposal and Bill Software as per PRC 2015, G.O;s and Other Information Teachers , Employees of Government and ZP, MP, Aided Managements. Assistant Manager Hr. Apart from this we also have some forms on simple medical consent forms for medical requirements. All the BSNL medical reimbursement claims will be processed as per the employee pay details only, if the claim exceeds the eligible amount, then the BSNL ERP portal doesn’t allow the claim in ESS login only, Let’s check the claiming process for new or rejected medical claims through BSNL ERP Portal at eportal.erp.bsnl.co.in.. How to submit BSNL Outdoor Medical Claim in BSNL ERP ESS portal Printable and fillable Member Reimbursement Medical Claim Form Designation: 3. • This form is to be used to seek reimbursement for out of pocket medical expenses pertaining to the treatment of an accepted condition. So download this template today! It should clearly instruct the employees to take the signature of the authority members of the hospital to the claim authentic for their medical condition. Use the drag and drop editor to remove, duplicate or add new fields in real time. Claim No. The patient has the right to any healthcare benefits they pay for or get through their job. So, check them out today! Name of Employee: 2. 3. Sudhirmhambare. I was admitted to the (Name of Hospital), for five/seven days. Hr Consultant. Emergency certificate (with signature and stamp of hospital/treated doctor) 3. All the bills such as doctor fees, bills of medicines purchased, bills of all the medical tests undergone, etc. Pay of the Govt. (Describe in your own words). 3 See yourUMR ID card for: *Name ofEmployer *Plan GroupNumber *Name ofMember (as it appear on the ID card) 4Patientname and date ofbirth must match UMR'seligibility file. Example - … You must carefully read and fill out each part of the form or else Medicare will send it back to you for you to complete and re-submit. “Typed Application” of the claimant regarding reimbursement of medical charges … Apart from this we also have templates on medical certificates that you might have a look at. Sub: Medical Bill Reimbursement Application. However, it includes a few pages of instructions, which can make it feel daunting. MEDICAL REIMBURSMENT BILL Note: - 1. • Please submit a separate reimbursement claim for each provider where an out of pocket expense was incurred. Edit, fill, sign, download Member Reimbursement Medical Claim Form online on Handypdf.com. MRI- CHECK LIST MRI - APPLICATION MRI - ESSENTIALITY CERTIFICATE FORM MRI- APPENDIX-II MRI - RECOMMENDATION MRI - NON CLAIM CERTIFICATE MRI - CERTIFICATE MRI - EMERGENCY ADMISSION CERTIFICATE MRI- ADVANCE DECLARATION MRI - FORMS-PDF- murali panamannapanamanna Medical Reimbursement Bill Preparation in SPARKആദ്യം BiMS ൽ ലോഗിൻ ചെയ്തു Allotment … Dear Employer’s Name, I am sending this letter to request reimbursement for the applicable medical expenses I have incurred due to (disease name). Essentiality certificate (with signature and stamp of hospital/treated doctor. (a) Name of the Principal CGHS Card Holder & : Designation : (b) CGHS Ben ID No. Medical Reimbursement Claim has to be submitted in duplicate. Different companies are tied up with insurance companies nowadays to offer medical help to the employees. reimbursement claim form 10 3 16 Best Medical Insurance. OPD slip from ESIC medical Hosiptal 2.ESIC Card of Employee 3. Have a look at this template and save your time by downloading it. Reimbursement from and duly sign by medical … That is why we suggest you have a look at this form template in PDF format. Age: 9. So, try them now! Application form and supporting documentation for MEPI claims. P.O. Keep a copyfor your records. (Signature of Controlling Officer) (Signature of the DDO) _____ INSTRUCTIONS 1. Provide the pharmacist with your claim number and ask that your prescription be processed through the WSIB on-line system. Or simply share the form’s direct URL in an email or social media post. Keep a copyfor your records. MEDICAL REIMBURSEMENT CLAIM FORM FOR INDOOR TREATMENT (BSNL) 1. ... Just write the bank account number and sign in the application form to authorise your bank to make payment in case of allotment. Application Form for Payment of Medical reimbursement Application Form for Payment of Medical Reimbursement page will be displayed below: APPLICATION FORM FOR REIMBURSEMENT OF MEDICAL CHARGES IN RESPECT OF SERVING/RETIRED GOVERNMENT SERVANT AND HIS/HER DEPENDENTS PART-A 1. Sr. Besides, equipped with a responsive layout, the form is compatible with smartphones and tablet displays. The Medicare reimbursement form, also known as the “Patient’s Request for Medical Payment,” is available in both English and Spanish on the Medicare website. To avoid processing delays, please include the following information with this form: Copy of itemized bill showing all services received. Or you can download this form sample which has framed the application for reimbursement. Servant as defined in FRs … Designed, Developed and Hosted by National Informatics Centre, Hyderabad. Guwahati +4 Others. Medical bills of parents and siblings who are wholly dependent on the employee can also be claimed as reimbursement. Manager -hr. Or simply share the form’s direct URL in an email or social media post. The medical reimbursement forms should begin by asking the details of the employee. Online TS Medical Reimbursement Proposal Submission at Medical Bills Website – SchoolEdu.Telangana.Gov.In is for School Education Department Employees and Retired Employees (Pensioners).. Medical Bill Claim Process Details and TS Medical Bill Reimbursement Proposals Submission process details provided here. Place of Duty: 6. ESI Reimbursement form is used to claim medical expenses when the insured person gets treatment in private hospitals. Name, designation, BPS, of the serving/retired Federal Government servant, (Alive/Deceased) _____ _____ 2. Collect billing data and process claims online with this medical reimbursement bill form template. Every employee is offered some percentage of money reimbursed by the insurance companies tied up with the company they work in. Mail your completed form/documents to PO Box 31370, Tampa, FL 33631 or fax to 813-283-3284 . If your company too requires the details that have been specified in this sheet, choose this template and save your time. General Manager-hr. Designed in the Doc format you can easily edit it if you want to make any other specifications in it. Form OWCP-915 can be used to seek reimbursement for expenses in regard to medical treatment, prescription medication and medical supplies. It should include their name, position, name of the … NC Industrial Commission News amp Announcements. It should record the employees’ investment during their illness period. Name of the patient and relationship with the claimant as dependent, as specified in rule 2(d) … All photocopies should be verified by the personnel of Medical Unit after showing original documents before submission of their application for reimbursement of medical bill/s. Medical Reimbursement Claim Form . The application for reimbursement of Medical Bill/s along with all . No worries for refund as the money remains in investor's account. Name and Designation & Section : (in Block Letter) 2. important: please read the attached instructions prior to submitting a claim to medicare send only the completed form to your medicare administrative contractor – include a copy of the This template is based on the checklist for the medical reimbursement claim form. Thanks for reading Karnataka State Government Employees Medical Reimbursement Sanctioned Circular . may be submit while claiming the bill with date-wise prescription. Although the process of claiming Medical Charges is somewhat difficult, however if the following rulings be kept in mind then this process can be made easy. Medical Reimbursement Charges is the amount that is claimed by the Govt Employee due to the illness or disease of his family, parents or himself. H.P.T.R.6 MEDICAL CHARGES REIMBURSEMENT FORM 1. Medical Reimbursement Rules, Application Form, How to Apply As per Rc.No.8878/ (D3-4) MB1 – 2010 Dated: 12-10-2010 Sub: - School Education Department – Medical Attendance – Medical Reimbursement proposals in respect of Teachers/HM’s and other Employees of Education Department – certain Instructions – Regarding. This medical bill reimbursement form can be shared anywhere online. Then configure autoresponder messages to give claimants peace of mind their request is up for review. Medical Reimbursement-Private hospitals-claim amount-GO(MS) N. 122/2020/fin dtd 23-11-2020: Medical Reimbursement-Instructions No. Please note, your bill must be paid in full before you can submit this request for reimbursement and all required documentation must be included with the request. If you are framing a form for the medical claim you need to specify different condition specification and medical requirements in it. Secondly, there is a mismatch of pension amount.. as per bank pass book records it shows Rs. Ramesan.pt. patient’s request for medical payment. This medical bill reimbursement form can be shared anywhere online. Provider Tax ID Diagnosis Codes - (not just description) Provider NPI CPT/Procedure Codes ... completed form and itemized bill. Name and Designation :––––––––––––––––––––. Box 31370 • Tampa, FL 33631 Use this claim form to be reimbursed for eligible out-of-pocket medical expenses. The medical advance bill form is a part of the claim form for medical reimbursement under the CGHS. Medical Reimbursement Form (in English)(241 KB ) Matta Va Dayitva (in Marathi) (64.9 KB ) No Objection Certificate for obtaining Passport (512 KB ) Charge Transfer Certificate Gazeted Officer Gen 93 M (in Marathi)(132 KB ) Charge Transfer Certificate Non Gazeted Officer (in Marathi)(103 KB ) Budget Estimation Form (3579 KB) If this happens, the claimant may be able to resolve the issue with a claim letter. If you are designing a medical reimbursement for the employee’s healthcare facility, you should identify the different treatment requirements to frame the form. The sample mentioned here is a highly specific claim form that along with recording employee details and instruction highlights the medical requirements in detail. Supplies Durable Medical. form and any required documents to 1 -8132833284OR MAIL to WellCare Member Reimbursement Department • P.O. This template is based on member reimbursement medical claims with several instructions. Birendra_c. You can also check out our templates on the medical evaluation form for framing more specific information. Medical Reimbursement Charges is the amount that is claimed by the Govt Employee due to the illness or disease of his family, parents or himself. Modify this employee medical reimbursement claim form example in any way you need, without writing a single line of code. You can choose this form example template if it can highlight your reimbursement criteria. All the bills such as doctor fees, bills of medicines purchased, bills of all the medical tests undergone, etc. I am enclosing all medical records pertaining to my treatment and hospitalization as well as the amount I am requesting for reimbursement … ESI Reimbursement form is used to claim medical expenses when the insured person gets treatment in private hospitals. This form is framed asking several details on medical situations that you can offer your employees to fill if they need medical reimbursements. But every insurance company provides some percentage of or the entire amount of the treatment expenses. So have a look at this template and check out if it can help you to cover your medical requirements. If your insurance company is offering help on the different types of serious health issues you should also retain a proper form to record the details. Note: This form may be used for claims for PEBB and SEBB Uniform Medical Plans. Dear Sir, I was suffering from (disease name) from last few months. It should also give instructions and ask for verification and signature of the employee. Original bills/cash-memos. There are different formats of framing a medical reimbursement form that different insurance companies provide to the employees. Or simply share the form’s direct URL in an email or social media post. Hazar189. and e-mail address, if any: 2. Hr Excutive. Framing a proper medical reimbursement form can save you from paying the amount which has been spent on the treatment. 2. With this medical reimbursement bill form, you can collect the data that you need in no time. Another format, Date… Administration Office, Medical Institution name… Institute Address… Sub: Request for Medical Bill Reimbursement. Medical Institution name… Institute Address… Sub: Request for Medical Bill Reimbursement. Reimbursement forms are made to get back the expenses an employee has made on the services, equipment, etc. It helps the insurance companies to check if the employee has used their particular limit of medical help from them or not. The Medical Reimbursement should be submitted to this office with the following documents 1. These bills could be for the purchase of medicines from pharmacies and medical shops, or medical treatment taken at public or private hospitals and clinics. How to File a Claim for Philhealth Reimbursement or Refund. Name and Designation : _____ 2. Please use the appropriate form below to request a health insurance reimbursement from SDCERS. Medical Reimbursement software & Proposal forms for AP/ Telangana Teachers / Employees 2020. We have designed different templates structuring medical reimbursement forms that you may try to get a quick reimbursement. Box 709718 Sandy, UT 84070-9718 Telephone: 844-234-4472 . Medical Bill Reimbursement Form Esic - PDF Download × Pbskumar2006. You can draw a proper column that can frame the name of the medicines along with their composition and charges. It should be written in formal business style and sent by certified mail, so the sender has proof of the time and date it was received. Period of Treatment: From_____ To _____ (Certificate issued by the Medical … What’s more, the ability to import that data into your accounting software eliminates the time and errors associated with data entry. The reimbursement form should be framed with medical expenses details criteria. If you require to design one form of that sort you can refer to this sample template that can help you to structure the form. 2Attachyour itemized statement (or fully legible copyof the bill) to the back of this form. 13. It advices the various ministries on legal matters as well as is allotted with the Attorney General of India etc whose services are shared by the Ministries. Having this template can help you to save your time so choose this template today! Medical advance bill form; The medical advance bill form is a part of the claim form for medical reimbursement under the CGHS. H.P.T.R.6 MEDICAL CHARGES REIMBURSEMENT FORM 1. For example, if you require a highly specific form to gather specific data this reimbursement form example is the best for you. Please complete a separate form for each family member. By using an online medical bill reimbursement form, you can have these expense reports delivered instantaneously to each person involved in processing the expenses. First, you can look up individual records or export them as a group to Excel, CSV or PDF format. City Retiree Health Reimbursement Forms. Medical Reimbursement Proposal and Bill Software as per PRC 2015, G.O;s and Other Information Teachers , Employees of Government and ZP, MP, Aided Managements. Have a look at them and choose the best for you. Although the process of claiming Medical Charges is somewhat difficult, however if the following rulings be kept in mind then this process can be made easy. Second, you can integrate with other web apps, bypassing the need to import data. enclose latest Reference Letter from AHC. So try this template today! Name of Doctor/Hospital: 11. Often insurance companies specify what documents they require as per their policies. Pl. MEDICAL CLAIM FORM Use this form to submit reimbursement requests for services received from a non-network provider. The Insured person or employer of the insured person should intimate the ESI dispensary before joining the patient in the private hospital and in most of the cases if the private hospital not referred by insurance officer of the particular ESIC dispensary then the claim will … To do that, you’ll need to fill out and mail a Medicare Patient’s Request for Medical Payment form (also known as the CMS-1490S claim form). Medical Bill Reimbursement Form Esic - PDF Download ... yes this is possible to claim the all medical bill from ESIC please make sure that you have to fulfill all the formalities like 1. Besides, equipped with a responsive layout, the form is compatible with smartphones and tablet displays. Or you can have this form template frame that has been framed with great specifications. Attach Cash-Memo duly verified. Office of the employee : 3. The form itself is relatively simple. Reimbursement forms are made to get back the expenses an employee has made on the services, equipment, etc. Here are sample reimbursement letters for medical expenses. Manager - Hr & Ir [email protected] Hr Executive. form cms-1490s (version 01/18) 1 department of health and human services centers for medicare & medicaid services . This free claim form sample is yours to personalize according to your situation. Application form for reimbursement of medical expenses / treatment of Jamia employees and It helps the insurance companies to check if the employee has used their particular limit of medical help from them or not. Please printclearly with black ink completing allrequired fields. You can also access our sample medical release forms if you need to prepare one for your reimbursement process. Email: health@sdcers.org (before sending, please read the important security note below. Please use a separate claimform for each health care professionaland for each familymember. Total expense (Money amount) are incurred. You also must explain, in detail, why you are submitting the reimbursement claim. … So, choose this template to save your time from designing it. Annexure – II (with amount, signature of the applicant and attestation) 2. We have some templates on the medical receipt that you might like to use. A. Member Medical Reimbursement Claim Form FAX Use this claim form to be reimbursed for eligible out Member Name _____ Member ID # _____ Address_____ City _____ State _____ ZIP Code: _____ Telephone:_____ Please provide a brief description of your request: Date of Service Provider Name Description of Service Amount Requested Total Amount of Reimbursement Request _____ I attest … supporting documents should be furnished within 6 (six) months from the date of the first visit for all retired employees and their dependents. Every detail bar has been left with an apt space that you can easily fill in the details in. If an employee gets injured on the job, reimbursing the expenses quickly is the right thing to do. The form is called the Patient Request for Medical Payment form. To this end, just copy and paste the provided embed snippet to insert it seamlessly into a web page. The Medicare reimbursement form, also known as the “Patient’s Request for Medical Payment,” is available in both English and Spanish on the Medicare website. 2. provider types are eligible for reimbursement for medical supplies durable medical equipment DME orthoses and prostheses' 'reimbursement claim form 10 3 16 Best Medical Insurance May 7th, 2018 - Claim Form In patient Treatment Day Care Procedures q Duly filled and signed Claim Form q Photocopy of ID card Photocopy of current year policy' Previous « … Provide customers with an online order form to request advertisement services. included in Bill No. It has to be mentioned by the forwarding /concern office (Chief Engineer) as to whether the amount claimed forreimbursement is as per the CGHS prescribed rate or not and it has also need to be certified that there is no need of any relaxation of rules in the instant case. Please reimburse this amount; I have attached all the necessary documents and Invoices. If you need to apply for reimbursement of medical expenses in your company this simple claim form can help you to frame it. It depends on the needs and detailing that defines the format of designing the form. MEDICAL CHARGES REIMBURSEMENT FORM 1. If your insurance company has promised to pay 100% percent reimbursement on medical treatments you must need to have a very specifically framed form. Reg.No: 4. Reimbursement request checklist I have completed or attached the following: Signed member reimbursement form with all sections clearly completed For medical and/or behavioral health claims, an itemized provider bill that includes: 1. Author: Kim Huynh Created Date: FORMS AND CERTIFICATES APPENDIX II FORM APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDANCE AND TREATMENT OF GOVERNMENT SERVANT AND THEIR FAMILIES 1. The form should also have space to record the medical tests, or ambulance service and consultancy details if it is used. That is why we suggest you have a look at this form that has been designed in a standard manner with specific information and instructions. This completed and signed reimbursement form b. Different insurance companies offer help of a certain amount for the medical needs of the employees. (a) Name of the Principal CGHS Card Holder & : Designation : (b) CGHS Ben ID No. A reimbursement form needs to have different other details rather than medical requirements. File Format : JPJ File Size : 67kb Number of Pages : 01 Scanned Copy : Yes Editable Text : No Password Protected : No Image Available : Yes Download Link Available : Yes Copy Text : No Print Enable : Yes Quality : High File size Reduced : No Password : No Cost : Free of cost. Modifications to the design and content are as easy as drag-and-drop—no coding needed! To request reimbursement, please submit the following to the address listed at the bottom of this form (any missing information may result in delay or denial of the request): a. Medical Bill Reimbursement Application Format. The amount in the Essentiality The form should also provide instruction to the employees on what extra document they need to attach with the form. Reimbursement Form In most cases, your claim related medications can be billed on-line by your pharmacist. Besides, equipped with a responsive layout, the form is compatible with smartphones and tablet displays. : (d) Ward Entitlement -Pvt./Semi-Pvt./General : Basic Pay (excluding Grade Pay) : (e) Full Address : (f) Mobile telephone No. Has to be filled in the application form to gather details on different treatment expenses services for... Excel, CSV or PDF format investment during their illness period information with this medical reimbursement form frame can you! 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Format, Date… Administration Office, medical Institution name… Institute Address… Sub: medical REIMBURSMENT note! Detail, why you are framing a form that along with recording employee details and instruction highlights the reimbursement. ) CGHS Ben ID No been spent on the treatment expenses individual records export. Form structure would be able to help you to save your time from it! Few pages of instructions, which can make it feel daunting template if it can help you to support and. Injured on the services, equipment, etc, CSV or PDF format personalize to. Example sheet is framed according to the reimbursement sheet much just download this template for your reimbursement process require highly... Designed, Developed and Hosted by National Informatics Centre, Hyderabad from the date of service/purchase employee. Serving/Retired Federal Government medical reimbursement bill form, ( Alive/Deceased ) _____ _____ 2 Officer ) ( signature of Controlling )... Template and save your time so choose this template is based on the services being for... Use the appropriate form below to request a health insurance reimbursement from SDCERS payment in case allotment! Are interested to do they have spent for some medical issues form for each health professionaland... Doctor fees, bills of all the medical reimbursement should be submitted to this end, just copy paste! Regard to medical treatment, prescription medication and medical requirements in detail ( b ) CGHS ID! Help you to frame it for medical requirements submitted for reimbursement by different terms and.... At this form sample template is one year from the date of service/purchase can download form. Used for claims for PEBB and SEBB Uniform medical Plans expense was incurred that! Onâ simple medical consent forms for medical requirements medical Institution name… Institute Address…:. Dear Sir, i was admitted to the employees the different medical requirements in it manager Hr. 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And/Or facility way you need in No time first from the patients form cms-1490s ( version 01/18 ) 1 of. Of admission to the treatment expenses the expenses an employee gets injured on the services being for! Of a certain amount for the medical advance bill form ; the medical form... You need not do much just download this template and check out our on. Real time and any required documents to 1 -8132833284OR mail to WellCare member reimbursement medical claims several. And Invoices a perfect reimbursement form can help you to frame it is one year from the employees what... For medical requirements medical reimbursement bill form different formats of framing a medical reimbursement claim form to file a claim form medical. A structure that can help you to structure the medical requirements to seek reimbursement for services. Asks the employees to WellCare member reimbursement claim for Philhealth reimbursement or Refund claimants... 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Patient has the right to any healthcare benefits they pay for or get through their job download this form templateÂ. Or social media post and detailing that defines the format of designing form! Stamp of hospital/treated doctor form cms-1490s ( version 01/18 ) 1 from SDCERS in an email or social media.... And consultancy details if it is used to seek reimbursement for out of pocket expense was incurred employee is important... Please include the following information with this form: copy of itemized bill of or entire! Address on your Aetna Medicare member ID Card Aetna Medicare member ID.. Up by the insurance companies with smartphones and tablet displays submitted for reimbursement of medical expenses,! Details rather than medical requirements No time the completed form, you can choose reimbursement... Original receipts and itemized bills to 1-866-474-4040 management options of this form: copy of itemized bill Affairs... Are made to get back the expenses an employee gets injured on the checklist for medical. Also provide instruction to the requirements that the patient has the right thing to do so it is used seek. Framing a medical reimbursement should medical reimbursement bill form provided so that its summed up amount can be used to reimbursement. Your requirements specifically autoresponder messages to give claimants peace of mind their request is up for.. Medical expenses details along with all and ask for different documents to be attached to the needs... Is used to seek reimbursement for expenses in regard to medical treatment, prescription medication and medical.! Po box 31370 • Tampa, FL 33631 use this claim form for INDOOR treatment ( ). Salary ( Basic pay + D.A ) /Pension ( as on 1.04.04 ): 5 requirements in it _____ 2! You may try to get the attention of the … this medical reimbursement exampleÂ. They require as per their policies bills incurred for self, spouse children... 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