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In addition, the information submitted may become a part of the patient’s permanent chart or treatment record at The Emily Program upon their utilization of The Emily Program services, and this information may be used in the planning of treatment and care provided to the patient. At the time the patient utilizes The Emily Program services, The Emily Program’s Notice of Privacy Practices and 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 the patient and the care provided to the patient.

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