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The data you submit on this type will likely be used internally for the needs of processing and responding to your request. It might be routed internally to be able to discover essentially the most acceptable member of workers to deal with your request and your contact info will solely be used to answer your inquiry in case you point out permission to take action.

As well as, the data submitted might turn into part of the affected person’s everlasting chart or therapy file at The Emily Program upon their utilization of The Emily Program providers, and this info could also be used within the planning of therapy and care supplied to the affected person. On the time the affected person makes use of The Emily Program providers, The Emily Program’s Discover of Privateness Practices and different HIPAA and data privateness and safety insurance policies will apply to the data submitted on this type and to some other info that The Emily Program maintains in regards to the affected person and the care supplied to the affected person.