Indian Health Service The Federal Health Program for American Indians and Alaska Natives
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To protect you, your family's, or your patient's privacy, we ask you DO NOT include any Personally Identifiable Information (PII) or Protected Health Information (PHI) on this form.
Examples of PII and PHI are: Personal Phone Number(s), Personal Address, Individual Health Condition(s), Social Security Number, Date of Birth (DOB), Patient Name (if not your own), and Patient Registration Number.