Appointment Request

HIPAA Privacy Notice & Consent for Online Submission of Health Information
Your Privacy Matters

We are committed to protecting your privacy and the security of your personal and health information. The information you provide through this form is protected under the Health Insurance Portability and Accountability Act (HIPAA) and will only be used for scheduling your autism assessment and related healthcare services.

Use & Disclosure of Your Information

By completing and submitting this form, you acknowledge and agree to the following:

• Collection & Use: The information you provide will be used to determine your eligibility for an autism evaluation and to contact you regarding appointment scheduling.
• Confidentiality: Your information will be stored securely and will not be shared with unauthorized individuals.
• Authorized Sharing: We may share your information only with authorized healthcare professionals and administrative staff involved in your evaluation, as well as with your health insurance provider (if applicable) for coverage verification.
• Voluntary Submission: Submission of this form is voluntary, and you may choose to provide only the information you are comfortable sharing. However, incomplete forms may delay the scheduling process.
• Secure Communication: While we take appropriate safeguards to protect your information, electronic submission of health data carries some security risks. If you prefer, you may contact our office by phone to schedule an appointment instead.
• Patient Acknowledgment & Consent
  ☑ I acknowledge that I have read and understood this HIPAA Privacy Notice.
  ☑ I consent to the collection, use, and secure storage of my health information for the purpose of scheduling an autism evaluation.
  ☑ I understand that this form does not establish a patient-provider relationship or guarantee an appointment until confirmed by the clinic.