Wisconsin Initial Refugee Health Assessment Page 6
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6F-42017 (Rev. 09/13)
Page 6 of 6
Medical Home:
Primary Provider:
Health System:
Screening Provider (If more than one agency is involved in health assessment, include information on both agencies.
Agency One:
Agency Two:
Contact Person:
Contact Person:
Address:
Address:
Telephone Number:
Telephone Number:
(
)
(
)
Fax:
Fax:
(
)
(
)
Submitter/Contact:
Contact Telephone Number:
(
)
Fax completed form to the Wisconsin Department of Health Services, Division of Public Health, Bureau of Communicable Diseases and
Emergency Response, Refugee Health Coordinator at (608) 266-0049 or mail to:
Wisconsin Division of Public Health
Attn: Refugee Health Coordinator
1 W. Wilson St. Rm 255
Madison, WI 53701-2659
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