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To assess your needs, we need to collect protected health information (PHI) from you. To comply with the Health Insurance Portability and Accountability Act of 1996, more commonly known as HIPAA, we will treat your PHI as confidential information and not disclose it to anyone other than as necessary to provide you with products and services. However, please note and understand that this form is not HIPAA compliant and the information is sent via encrypted emails that are also not HIPAA compliant. By submitting information through this form, you acknowledge and understand the terms.