I First Name* Last Name* understand that this application will be reviewed by the Warrior Salute Veteran Services Nucor Team and Medical Director, and that a clinical assessment may need to be completed to determine eligibility. I understand that if further clinical assessments need to be completed, the information regarding the assessment will be shared amongst the Warrior Salute Veteran Services Team.
Initial I hearby give permission to Warrior Salute Veteran Services to receive information from:Person(s): Agency: Address: Street Address Address Line 2 City State Zip Area Code Phone Number Email
I understand that this authorization covers only the information indicated and that Warrior Salute Veteran Services will maintain the confidentiality of the information. Warrior Salute Veteran Services is prohibited from disclosure of any records it receives through use of this release. I may revoke my authorization at any time with a written request. This authorization is valid from one year from the date signed. The information obtained from the use of this release may only be used for the purpose of which it was intended. Any other use of this information is in direct violation of Confidentiality and is punishable by law.