Wellness Intake Information
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I acknowledge that I have been provided a copy of the Practice's "HIPAA Privacy Policy Notice", which describes the Practice's obligation to ensure the privacy of my health information. The HIPAA Privacy Notice also describes how the Practice may use and disclose my health information for treatment, payment and health care operations. I know that I have the right to review the Practice's HIPAA Privacy Notice and to ask questions about it. I understand that the Practice is required to maintain the privacy of my health information in accordance with the terms of its HIPAA Privacy Notice.

I further acknowledge that the Practice can change it's HIPAA Privacy Notice in the future and that I can receive a copy of the Practice's current Privacy Notice at any time.

I understand that I have the right to request that the Practice restricts its uses and disclosures of my health information for treatment, payment or health care operations. If my restrictions are accepted by the Practice, these restrictions will be binding on the Practice. I also understand that the Practice is not required to agree to any restrictions.

By signing this form, I consent to the Practice's use and disclosure of my health information for treatment, payment, and health care operations. I understand that I have the right to revoke the consent at any time in writing, but if I do, my revocation will not affect any actions the Practice has already taken in reliance of this consent.

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Hours of Operation

Monday-Friday

8am-5pm

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100 Allawood Court, Suite. 110.

Simpsonville SC, USA 29681

Phone: (864) 525-2654

Fax: (864) 757-8811

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