{"id":2407,"date":"2021-09-22T09:29:02","date_gmt":"2021-09-22T13:29:02","guid":{"rendered":"https:\/\/acandakids.com\/?page_id=2407"},"modified":"2021-09-22T09:44:01","modified_gmt":"2021-09-22T13:44:01","slug":"client-intake-form","status":"publish","type":"page","link":"https:\/\/1022.acandakids.com\/client-intake-form\/","title":{"rendered":"Client Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2407\" class=\"elementor elementor-2407\">\n\t\t\t\t\t\t<div class=\"elementor-inner\">\n\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-ca03ea1 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"ca03ea1\" data-element_type=\"section\" 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class=\\\"table table-bordered\\\">\\n<tbody>\\n<tr>\\n<td width=\\\"60%\\\"><h4 style=\\\"text-align: left;\\\"><span style=\\\"font-weight: 700; font-size:54px; color: #1e73be;\\\">2<\\\/span><span style=\\\"font-weight: 400; font-size:36px\\\">\\\/5<\\\/span><\\\/h4>\\n  <h4 style=\\\"font-size: 30px;line-height: 32px;\\\"><br>Please insert client information<\\\/h4>\\n<\\\/td>\\n  <td width=\\\"40%\\\"><p><img src=\\\"https:\\\/\\\/acandassociates.com\\\/wp-content\\\/uploads\\\/2014\\\/12\\\/04_physician.png\\\" style=\\\"width: 460px;\\\"><\\\/p>\\n<\\\/td>\\n<\\\/tr>\\n<\\\/tbody>\\n<\\\/table>\\n<p><br><\\\/p>\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"html_1603834618598\",\"cellcid\":\"c16753\",\"drawerDisabled\":\"\",\"field_label\":\"HTML\",\"field_key\":\"html_1603834618598\",\"id\":8,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<table class=\\\"table 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nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Louisiana\",\"value\":\"LA\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"18\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Maine\",\"value\":\"ME\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"19\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Michigan\",\"value\":\"MI\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"22\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Minnesota\",\"value\":\"MN\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"23\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Mississippi\",\"value\":\"MS\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"24\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Missouri\",\"value\":\"MO\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"25\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Nevada\",\"value\":\"NV\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"28\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"New Hampshire\",\"value\":\"NH\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"29\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"New Jersey\",\"value\":\"NJ\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"30\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"New Mexico\",\"value\":\"NM\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"31\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"New 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Ohio\",\"value\":\"OH\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"35\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Oklahoma\",\"value\":\"OK\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"36\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Oregon\",\"value\":\"OR\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"37\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a 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Please upload documents in PDF format or as JPEG files.<\\\/span><\\\/h4><\\\/td>  <td width=\\\"40%\\\"><p><img src=\\\"https:\\\/\\\/mytherapyprograms.com\\\/wp-content\\\/uploads\\\/2021\\\/06\\\/02_diagnosis_doctor.png\\\" style=\\\"width: 442px;\\\"><\\\/p><\\\/td><\\\/tr><\\\/tbody><\\\/table><p><br><\\\/p>\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"html_1612235539826\",\"cellcid\":\"c16820\",\"drawerDisabled\":\"\",\"field_label\":\"HTML Copy\",\"field_key\":\"html_1612235539826\",\"oldCellcid\":\"c15117\",\"id\":36,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<table class=\\\"table table-bordered\\\"><tbody><tr><td width=\\\"60%\\\"><h4 style=\\\"text-align: left;\\\"><span style=\\\"font-weight: 700; font-size:54px; color: #1e73be;\\\">3<\\\/span><span style=\\\"font-weight: 400; font-size:36px\\\">\\\/5<\\\/span><\\\/h4>  <h4 style=\\\"font-size: 30px;line-height: 32px;\\\"><br>Tell us about the client's condition<\\\/h4>    <h4 style=\\\"font-size: 14px;\\\"><span style=\\\"font-weight: 600;\\\">Time to tell us about the client's health condition and upload documents, clinical exams, and images that you believe are important for the video consultation. Please upload documents in PDF format or as JPEG files.<\\\/span><\\\/h4><\\\/td>  <td width=\\\"40%\\\"><p><img src=\\\"https:\\\/\\\/mytherapyprograms.com\\\/wp-content\\\/uploads\\\/2021\\\/06\\\/02_diagnosis_doctor.png\\\" style=\\\"width: 442px;\\\"><\\\/p><\\\/td><\\\/tr><\\\/tbody><\\\/table><p><br><\\\/p>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":2,\"idAttribute\":\"id\",\"label\":\"Medical Condition\",\"type\":\"listselect\",\"key\":\"listselect_1612235663792\",\"label_pos\":\"above\",\"required\":0,\"options\":[{\"errors\":[],\"max_options\":\"0\",\"order\":\"0\",\"new\":\"\",\"options\":[],\"label\":\"--\",\"value\":\"\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"order\":\"1\",\"new\":\"\",\"options\":[],\"label\":\"Alzheimer's\",\"value\":\"alzheimer-s\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Autism \\\/ Sensory Processing\",\"value\":\"autism\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"2\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Attention Deficit Hyperactive Disorder \\\/ ADHD\",\"value\":\"adhd\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"3\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"},{\"errors\":[],\"max_options\":\"0\",\"order\":\"4\",\"new\":\"\",\"options\":[],\"label\":\"Chronic Pain\",\"value\":\"chronic-pain\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"order\":\"5\",\"new\":\"\",\"options\":[],\"label\":\"Dementia\",\"value\":\"dementia\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"order\":\"6\",\"new\":\"\",\"options\":[],\"label\":\"Early Intervention\",\"value\":\"early-intervention\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"},{\"errors\":[],\"max_options\":\"0\",\"order\":\"7\",\"new\":\"\",\"options\":[],\"label\":\"Entering Work Force \\\/ Post Injury\",\"value\":\"entering-work-force-post-injury\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"order\":\"8\",\"new\":\"\",\"options\":[],\"label\":\"Global Delays\",\"value\":\"global-delays\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"},{\"errors\":[],\"max_options\":\"0\",\"order\":\"9\",\"new\":\"\",\"options\":[],\"label\":\"Learning Disabilities\",\"value\":\"learning-disabilities\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"},{\"errors\":[],\"max_options\":\"0\",\"order\":\"10\",\"new\":\"\",\"options\":[],\"label\":\"Medically Fragile\",\"value\":\"medically-fragile\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"},{\"errors\":[],\"max_options\":\"0\",\"order\":\"11\",\"new\":\"\",\"options\":[],\"label\":\"Premature Infants\",\"value\":\"premature\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"},{\"errors\":[],\"max_options\":\"0\",\"order\":\"12\",\"new\":\"\",\"options\":[],\"label\":\"Stroke\",\"value\":\"stroke\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"order\":\"13\",\"new\":\"\",\"options\":[],\"label\":\"Traumatic Brain Injury \\\/ TBI\",\"value\":\"tbi\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"},{\"errors\":[],\"max_options\":\"0\",\"order\":\"14\",\"new\":\"\",\"options\":[],\"label\":\"other\",\"value\":\"other\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"cellOrder\":1,\"drawerDisabled\":\"\",\"field_label\":\"Medical Condition\",\"field_key\":\"listselect_1612235663792\",\"oldCellcid\":\"c7828\",\"saved\":\"\",\"nicename\":\"Medical 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I hereby grant and authorize Amee Cohen and Associates LLC the right to use of any and all pictures or video taken of me for therapeutic, educational, research and other non-commercial purposes.\\n<\\\/p>\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"html_1603838323667\",\"cellcid\":\"c16938\",\"cellOrder\":2,\"drawerDisabled\":\"\",\"field_label\":\"HTML Copy\",\"field_key\":\"html_1603838323667\",\"id\":105,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p style=\\\"font-size: 11px;line-height:13px\\\">I have downloaded (<a href=\\\"http:\\\/\\\/acandassociates.com\\\/pdf\\\/ACANDA-Photo-Video-Consent-Form.pdf\\\" target=\\\"_blank\\\">click here to download<\\\/a>) and read the photo use release form. 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I hereby grant and authorize Amee Cohen and Associates LLC the right to provide Telehealth\\\/Teletherapy Services. This authorization shall continue indefinitely, unless i otherwise revoke said authorization in writing.\\n<\\\/p>\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"teletherapy_consent_content_1607104098096\",\"cellcid\":\"c16942\",\"cellOrder\":2,\"drawerDisabled\":\"\",\"field_label\":\"teletherapy consent content\",\"field_key\":\"teletherapy_consent_content_1607104098096\",\"id\":107,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p style=\\\"font-size: 11px; line-height:13px\\\">I have downloaded (<a href=\\\"http:\\\/\\\/acandassociates.com\\\/pdf\\\/ACANDA-Teletherapy-Consent-Form.pdf\\\" target=\\\"_blank\\\">click here to download<\\\/a>) and read teletherapy consent form. I hereby grant and authorize Amee Cohen and Associates LLC the right to provide Telehealth\\\/Teletherapy Services. This authorization shall continue indefinitely, unless i otherwise revoke said authorization in writing.\\n<\\\/p>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":8,\"idAttribute\":\"id\",\"label\":\"HTML\",\"type\":\"html\",\"default\":\"<h6 style=\\\"font-size: 10px;\\\">This form will be securely received, treated, and stored in accordance with federal and state guidelines for sending, receiving, and storing private client health information. Any client information is privileged and confidential, intended only for the use of the Amee Cohen & Associates physician or therapist for the purposes of assessment, diagnostic impression, opinion, and recommendations regarding the video consultation process.<\\\/h6>\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_background-color\":\"#dae3e8\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":1,\"wrap_styles_advanced\":\"padding: 20px 0px 0 20px;\",\"label_styles_border\":\"\",\"label_styles_color\":\"#ffffff\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"html_1607018097691\",\"cellcid\":\"c16945\",\"drawerDisabled\":\"\",\"field_label\":\"HTML\",\"field_key\":\"html_1607018097691\",\"id\":108,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<h6 style=\\\"font-size: 10px;\\\">This form will be securely received, treated, and stored in accordance with federal and state guidelines for sending, receiving, and storing private client health information. Any client information is privileged and confidential, intended only for the use of the Amee Cohen & Associates physician or therapist for the purposes of assessment, diagnostic impression, opinion, and recommendations regarding the video consultation process.<\\\/h6>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":9,\"idAttribute\":\"id\",\"label\":\"Divider\",\"type\":\"hr\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"key\":\"hr_1603837674908\",\"cellcid\":\"c16948\",\"field_label\":\"Divider\",\"field_key\":\"hr_1603837674908\",\"id\":109,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"label_pos\":\"above\",\"parentType\":\"hr\",\"element_templates\":[\"hr\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":10,\"idAttribute\":\"id\",\"label\":\"\",\"type\":\"html\",\"default\":\"<p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">If you have any questions about this Notice please contact our Privacy Officer CHRISTIAN KATOPODIS.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. \\\"Protected health information\\\" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Your protected health information may be used and disclosed by your therapist, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your therapist's practice.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Following are examples of the types of uses and disclosures of your protected health information that your therapist's office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other therapists who may be treating you. For example, your protected health information may be provided to a therapist to whom you have been referred to ensure that the therapist has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another therapist or health care provider (e.g., a specialist or laboratory) who, at the request of your therapist, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your therapist.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your therapist's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We will share your protected health information with third party business associates that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We may use or disclose your demographic information and the dates that you received treatment from your therapist, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made incompliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA- regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice's premises) and it is likely that a crime has occurred.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Workers Compensation: We may disclose your protected health information as authorized to comply with workers compensation laws and other similar legally-established programs.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your therapist created or received your protected health information in the course of providing care to you.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Uses and Disclosures of Protected Health Information Based upon Your Written Authorization<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your therapist may, using professional judgement, determine whether the disclosure is in your best interest.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">2.YOUR RIGHTS<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your therapist and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Your therapist is not required to agree to a restriction that you may request. If your therapist does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your therapist. You may request a restriction by sending us a written request to AMEE COHEN & ASSOCIATES@ 53 Ash Drive, Cooper City, FL 33026-1102<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You may have the right to have your therapist amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">3.COMPLAINTS<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You may contact our Privacy Officer, CHRISTIAN KATOPODIS at 561.767.4421 or e-Mail info@acandassociates.com for further information about the complaint process. This notice was published and becomes effective on 08\\\/01\\\/2010<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">For more information about HIPAA or to file a complaint, please contact:<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">The U.S. Department of Health and Human Services<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Office of Civil Rights<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">200 Independence Avenue SW<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Washington, D.C. 20201 877-696-6775 (toll free)<\\\/span><\\\/p>\",\"container_class\":\"overflowcont\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"10px\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":1,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"p_1614268312336\",\"cellcid\":\"c16951\",\"cellOrder\":2,\"drawerDisabled\":\"\",\"field_label\":\"\",\"field_key\":\"p_1614268312336\",\"wrap_styles_background-color\":\"#f9f9f9\",\"wrap_styles_border-style\":\"\",\"wrap_styles_border-color\":\"\",\"wrap_styles_display\":\"block\",\"wrap_styles_advanced\":\"    height: 300px;\\n    max-width: 80%;\\n    overflow: auto;\\n    border-radius: 5px;\\n    border: 1px solid #dbdbdb;\\n    background: #f7f7f7;\",\"label_styles_border-color\":\"\",\"id\":110,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">If you have any questions about this Notice please contact our Privacy Officer CHRISTIAN KATOPODIS.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. \\\"Protected health information\\\" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Your protected health information may be used and disclosed by your therapist, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your therapist's practice.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Following are examples of the types of uses and disclosures of your protected health information that your therapist's office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other therapists who may be treating you. For example, your protected health information may be provided to a therapist to whom you have been referred to ensure that the therapist has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another therapist or health care provider (e.g., a specialist or laboratory) who, at the request of your therapist, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your therapist.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your therapist's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We will share your protected health information with third party business associates that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We may use or disclose your demographic information and the dates that you received treatment from your therapist, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made incompliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA- regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice's premises) and it is likely that a crime has occurred.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Workers Compensation: We may disclose your protected health information as authorized to comply with workers compensation laws and other similar legally-established programs.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your therapist created or received your protected health information in the course of providing care to you.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Uses and Disclosures of Protected Health Information Based upon Your Written Authorization<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your therapist may, using professional judgement, determine whether the disclosure is in your best interest.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">2.YOUR RIGHTS<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your therapist and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Your therapist is not required to agree to a restriction that you may request. If your therapist does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your therapist. You may request a restriction by sending us a written request to AMEE COHEN & ASSOCIATES@ 53 Ash Drive, Cooper City, FL 33026-1102<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You may have the right to have your therapist amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">3.COMPLAINTS<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">You may contact our Privacy Officer, CHRISTIAN KATOPODIS at 561.767.4421 or e-Mail info@acandassociates.com for further information about the complaint process. This notice was published and becomes effective on 08\\\/01\\\/2010<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">For more information about HIPAA or to file a complaint, please contact:<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">\\u00a0<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">The U.S. Department of Health and Human Services<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Office of Civil Rights<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">200 Independence Avenue SW<\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\"><br><\\\/span><\\\/p><p style=\\\"line-height: 13px;\\\"><span style=\\\"font-size: 11px;\\\">Washington, D.C. 20201 877-696-6775 (toll free)<\\\/span><\\\/p>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":11,\"idAttribute\":\"id\",\"label\":\"Notice of Privacy Practice\",\"type\":\"checkbox\",\"cellcid\":\"c16951\",\"key\":\"notice_of_privacy_practice_1607021183227\",\"label_pos\":\"right\",\"required\":1,\"container_class\":\"\",\"element_class\":\"\",\"manual_key\":\"\",\"disable_input\":0,\"admin_label\":\"\",\"help_text\":\"<p><br><\\\/p>\",\"desc_text\":\"\",\"default_value\":\"unchecked\",\"checked_value\":\"Checked\",\"unchecked_value\":\"Unchecked\",\"checked_calc_value\":\"\",\"unchecked_calc_value\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_display\":\"inline\",\"wrap_styles_float\":\"left\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_display\":\"inline\",\"label_styles_float\":\"left\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"cellOrder\":3,\"drawerDisabled\":\"\",\"default\":\"unchecked\",\"field_label\":\"Notice 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Practice.<\\\/p>\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"html_1614268292483\",\"cellcid\":\"c16951\",\"cellOrder\":4,\"drawerDisabled\":\"\",\"field_label\":\"HTML Copy Copy\",\"field_key\":\"html_1614268292483\",\"id\":112,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p style=\\\"font-size: 11px;line-height:13px\\\">I have reviewed and downloaded (<a href=\\\"http:\\\/\\\/acandassociates.com\\\/pdf\\\/ACANDA-Notice-of-Privacy-Practice.pdf\\\" target=\\\"_blank\\\">click here to download<\\\/a>) a copy of<br>the Notice of Privacy Practice.<\\\/p>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":13,\"idAttribute\":\"id\",\"type\":\"listselect\",\"label\":\"How did you find us?\",\"key\":\"how_did_you_find_us_1598295813995\",\"label_pos\":\"above\",\"required\":0,\"options\":[{\"errors\":[],\"max_options\":\"0\",\"order\":\"0\",\"new\":\"\",\"options\":[],\"label\":\"---\",\"value\":\"\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra 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