Your privacy is important to us. The information you provide on this form is protected under the Health Insurance Portability and Accountability Act (HIPAA). We are committed to safeguarding your health information and ensuring that all personal health details you share remain confidential. The data you submit will only be used for the purposes stated and will not be disclosed without your consent, unless required by law.
By submitting this form, you acknowledge that you understand and agree to the privacy practices outlined in our Privacy Policy.
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