By clicking “submit” below, you are indicating that you understand and agree to these terms regarding the use of your information:
The information you submit on this form will be used internally for the purposes of processing and responding to your request. It may be routed internally in order to find the most appropriate member of staff to handle your request and your contact information will only be used to respond to your inquiry if you indicate permission to do so.
In addition, the information submitted may become a part of your patient’s permanent chart or treatment record at The Emily Program upon his or her utilization of The Emily Program services and this information may be used in the planning of treatment and care provided to your patient. At the time your patient utilizes The Emily Program's services, The Emily Program's Notice of Privacy Practices, other HIPAA and information privacy and security policies will apply to the information submitted on this form and to any other information that The Emily Program maintains about your patient and the care provided to your patient.