By clicking “Ship” beneath, you’re indicating that you just perceive and agree to those phrases relating to the usage of your info:
The data you submit on this kind can be used internally for the needs of processing and responding to your request. It could be routed internally with the intention to discover essentially the most acceptable member of employees to deal with your request and your contact info will solely be used to reply to your inquiry if you happen to point out permission to take action.
As well as, the knowledge submitted might grow to be part of the affected person’s everlasting chart or therapy document 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 knowledge privateness and safety insurance policies will apply to the knowledge submitted on this kind and to some other info that The Emily Program maintains in regards to the affected person and the care supplied to the affected person.