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Wounded Ill & Injured Referral Application

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The information contained in this worksheet is privileged and confidential and/or protected health information (PHI) and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA). This worksheet is intended for the sole use of the individual or entity to whom it is addressed. If you are not the intended recipient, you are notified that any use, dissemination, distribution, printing or copying of this worksheet is strictly prohibited and may subject you to criminal or civil penalties. If you have received this worksheet in error, please contact the sender immediately and delete this worksheet and any attachments from any computer.

 

The information herein is For Official Use Only (FOUO) which must be protected under the Freedom of Information Act of 1966 and Privacy Act of 1974, as amended. Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in criminal and/or civil penalties.