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UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) <br />CONCLUSION <br />Other Notes <br />NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information <br />which is for the sole use of the intended recipient(s). Any unauthorized review, use, dlsciosure, or distribution is prohibited If you are not the intended <br />recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used <br />only to aid in providing healthcare services to federal prisoners Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be <br />reported as such. <br />UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) <br />Form USM -218 <br />Page 21 of 22 Rev. 07121 <br />