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HIPAA Privacy Disclaimer

I acknowledge that the information I provide is protected under the Health Insurance Portability and Accountability Act (HIPAA). All personal health information (PHI) shared with Village of Privilege will remain confidential and will not be disclosed to any third party without my written consent, except as required or permitted by law. By signing this form, I authorize Village of Privilege to use and/or disclose my PHI for purposes of treatment, payment, or healthcare operations, in compliance with HIPAA regulations.