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Patient Referrals

Birthday
Month
Day
Year
Type of Residence
Personal Home
Nursing Home
Hospice Home
Hospital
Assisted Living
Services Needed
Preferred Agency (Wound Care)
Insurance Type
Medicare
Medi-Cal

By submitting patient information through this website, you acknowledge and agree to the following:


  1. Protected Health Information (PHI): Any patient information submitted through this portal may include Protected Health Information (PHI) as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

  2. Confidentiality: We are committed to maintaining the confidentiality, integrity, and security of all PHI submitted. PHI will only be used or disclosed as permitted by HIPAA and other applicable laws.

  3. Permitted Use: Information submitted through this site will be used solely for the purpose of coordinating patient care, referrals, treatment, and/or related healthcare operations as authorized.

  4. Security Measures: This website uses secure transmission protocols and safeguards to protect PHI against unauthorized access, use, or disclosure. Despite these safeguards, no system can be guaranteed to be 100% secure, and you acknowledge the inherent risks of electronic transmission.

  5. Provider Responsibility: By submitting PHI, you represent and warrant that you are authorized under HIPAA and applicable state law to disclose such information for treatment, payment, or healthcare operations, and that you have obtained any necessary patient consents or authorizations.

  6. No Unauthorized Use: PHI submitted through this portal will not be sold, shared, or used for marketing purposes without appropriate authorization.

  7. Your Agreement: By continuing, you agree that you have read and understood this HIPAA Privacy & Security Notice and that you are submitting PHI in compliance with all applicable laws and regulations.


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