{"id":1459,"date":"2016-01-06T12:22:59","date_gmt":"2016-01-06T20:22:59","guid":{"rendered":"https:\/\/www.hiriskob.com\/staging\/?page_id=1459"},"modified":"2022-06-09T20:21:12","modified_gmt":"2022-06-10T03:21:12","slug":"register","status":"publish","type":"page","link":"https:\/\/www.hiriskob.com\/staging\/register\/","title":{"rendered":"Create an Account"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_34' style='display:none'>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_34'  action='\/staging\/wp-json\/wp\/v2\/pages\/1459' data-formid='34' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_34' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_34_6\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_6\" ><h3>Welcome to the Comprehensive Maternal-Fetal Medicine Center Online Patient Center<\/h3><\/div><fieldset id=\"field_34_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_34_1'>\n                            \n                            <span id='input_34_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_34_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_34_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_34_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_34_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_34_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_34_2\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_2\" ><label class='gfield_label gform-field-label' for='input_34_2'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_34_2' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_34_5\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_5\" >(Your user name and password will be emailed to the address you provide.)<\/div><div id=\"field_34_3\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_3\" ><label class='gfield_label gform-field-label' for='input_34_3'>NOTICE OF PRIVACY PRACTICES<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_3' id='input_34_3' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'>Effective Date: 4\/20\/2015 \n\nTHIS 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.\n\nWe understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others.  We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information.  It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer listed above.\n\nA.   How This Medical Practice May Use or Disclose Your Health Information\n\nThe medical record is the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:\n\n1.\tTreatment.  We use medical information about you to provide your medical care.  We \tdisclose medical information to our employees and others who are involved in \tproviding the \tcare you need. For example, we may share your medical information with other physicians \tor other health care providers who will provide services that we do not provide or we may share \tthis information with a pharmacist who needs it to dispense a prescription to you, or a \tlaboratory that performs a test.  We may also disclose medical information to members of \tyour family or others who can help you when you are sick or injured, or following your death \n\t\n2.\tPayment.  We use and disclose medical information about you to obtain payment for  \tthe \tservices we provide.   For example, we give your health plan the information it requires for \tpayment. We may also disclose information to other health care providers to assist them  \tin obtaining payment for services they have provided to you.\n\n3.\tHealth Care Operations. We may use and disclose medical information about you to operate \tthis medical practice. For example, we may use and disclose this information to review and\timprove the quality of care we provide, or the competence and qualifications of our professional \tstaff. Or we may use and disclose this information to get your health plan to authorized  \tservices or referrals. We may also use and disclose this information as necessary for \tmedical reviews, legal services and audits, including fraud and abuse detection and \t\ncompliance programs and business planning and management. We may also share your \tmedical information with our &quot;business \tassociates,&quot; such as our billing service, that perform \tadministrative services for us. We have a written contract with each of these business \tassociates that contains terms requiring them and their subcontractors to protect the \tconfidentiality and security of your medical information. Although federal law does not \tprotect health information which is disclosed to someone other than another healthcare \tprovider, health plan, healthcare clearinghouse, or one of their business associates,  \tCalifornia law prohibits all  recipients  of  healthcare  information  from  further \tdisclosing it except as specifically required or permitted by law.  We may also share \tyour information with other health care providers, health care clearinghouses or health plans \tthat have a  relationship with you, when they request this information to help them with \ttheir quality assessment and improvement activities, their patient-safety activities, their \tpopulation-based efforts to improve health or reduce health care  costs, protocol development, \n\tcase management or care coordination activities, their review of competence, \tqualifications \tand performance of health care professionals, their training programs, their accreditation, \tcertification or licensing activities, their activities related to contracts of health insurance or \thealth benefits, or their health care fraud and abuse detection and compliance efforts. \t\t[Participants in organized health care arrangements only should add: We may also share \tmedical information about you with the other health care providers, health care clearinghouses \tand health plans that participate with us in &quot;organized health care arrangements&quot; \t(OHCAs) for any of the OHCAs&#039; health care operations. OHCAs include hospitals, physician \torganizations, health plans, and other entities which collectively provide health care services. \tA listingof the OHCAs we participate in is available from the Privacy Official.]\n\n4.\t[Optional: Appointment Reminders. We may use and disclose medical information to contact \tand remind you about appointments. If you are not home, we may leave this information on your \tanswering machine or in a message left with the person answering the phone \n\t\n 5.\tSign-in Sheet.  We may use and disclose medical information about you by having you sign in \twhen you arrive at our office. We may also call out your name when we are ready to see \tyou.\n\n6.\tNotification and Communication with Family. We may disclose your health information to \tnotify or assist in notifying a family member, your personal representative or another person \tresponsible for your care about your location your general condition or, unless you have \tinstructed us otherwise, in the event of your death. In the event of a disaster, we may disclose \tinformation to a relief organization so that they may coordinate these notification efforts.  We \tmay also disclose information to someone who is involved with your care or helps pay for \tyour care.  If you are able and available to agree or object, we will give you the opportunity to \tobject prior to making these disclosures, although we may disclose this information in a disaster \teven over your \tobjection if we believe it is necessary to respond to the \temergency \tcircumstances. If you are unable or unavailable to agree or object, our health \tprofessional \twill use their best judgment in communication with your family and others.\n\n\t7.\tMarketing. Provided we do not receive any payment for making these communications, we may \tcontact you to encourage you to purchase or use products or services related to your treatment, \tcase management or care coordination, or to direct or recommend other treatments, therapies, \thealth care providers or settings of care that may be of interest to you. We may similarly describe \tproducts or services provided by this practice and tell you which health plans we participate in., \tWe may receive financial compensation to talk with you face-to-face, to provide you with small \tpromotional gifts, or to cover our cost of reminding you to take and refill your medication or \totherwise communicate about a drug or biologic that is currently prescribed for you, but only if \tyou either: (1) have a chronic and seriously debilitating or life-threatening condition and the \tcommunication is made to educate or advise you about treatment options and otherwise maintain \tadherence to a prescribed course of treatment, or (2) you are a current health plan enrollee and \tthe communication is limited to the availability of more cost-effective pharmaceuticals. If we \tmake  these  communications while  you  have  a  chronic  and  seriously  debilitating  or  life- \tthreatening condition, we will provide notice of the following in at least 14-point type: (1) the f\tact  and  source of  the  remuneration; and  (2)  your right to  opt-out of  future remunerated \tcommunications by calling the communicator&#039;s toll-free number. We will not otherwise use or \tdisclose your medical information for marketing purposes or accept any payment for other \tmarketing communications without your prior written authorization. The authorization will \tdisclose whether  we  receive any  financial  compensation  for  any  marketing  activity  you \tauthorize, and  we will  stop  any  future  marketing  activity  to  the  extent  you  revoke  that \tauthorization.\n\n8.\tSale of Health Information. We will not sell your health information without your prior written \tauthorization. The authorization will disclose that we will receive compensation for your health \tinformation if you authorize us to sell it, and we will stop any future sales of your information to \tthe extent that you revoke that authorization.\n\n9.\t\tRequired by Law.  As required by law, we will use and disclose your health information, but we \twill limit our use or disclosure to the relevant requirements of the law. When the law requires us \tto  report  abuse,  neglect  or  domestic violence, or respond to judicial or  administrative \tproceedings, or to law enforcement officials, we will further comply with the requirement set \tforth below concerning those activities.\n\n10.\t\tPublic Health.  We may, and are sometimes required by law to disclose your health information \tto public health authorities for purposes related to: preventing or controlling disease, injury or \tdisability; reporting child, elder  or  dependent adult  abuse  or  neglect;  reporting  domestic \tviolence, reporting to the Food and Drug Administration problems with products and reactions to \tmedications; and reporting disease or infection exposure. When we report suspected elder or \tdependent adult abuse or domestic violence, we will inform you or your personal representative \tpromptly unless in our best professional judgment, we believe the notification would place you \tat risk of serious harm or would require informing a personal representative we believe is \tresponsible for the abuse or harm \n\n11.\t\tHealth Oversight Activities. We may, and are sometimes required by law to disclose your health \tinformation to health oversight agencies during the course of audits, investigations, inspections, \tlicensure, and other proceedings, subject to the limitations imposed by federal and California law.\n\n12.\t\tJudicial and Administrative Proceedings. We may, and are sometimes required by law, to \tdisclose your health information in the course of any administrative or judicial proceeding to the \textent expressly authorized by a court or administrative order. We may also disclose information \tabout you in response to a subpoena, discovery request or other lawful process if reasonable \tefforts have been made to notify you of the request and you have not objected, or if your \tobjections have been resolved by a court or administrative order.\n\n13.\t\tLaw Enforcement. We may, and are sometimes required by law, to disclose your health \tinformation to a law enforcement official for purposes such as identifying of locating a suspect, \tfugitive, material witness or missing person, complying with a court order, warrant, grand jury \tsubpoena and other law enforcement purposes.\n\n14.\t\tCoroners. We may, and are often required by law, to disclose your health information to \t                     \tcoroners in connection with their investigations of deaths.\n\n15.\tOrgan or Tissue Donation.  We may disclose your health information to organizations \t\t     \t\tinvolved in procuring, banking or transplanting organs and tissues.\n\n16.\tPublic Safety.  We may, and are sometimes required by law, to disclose your health \n    information to appropriate persons in order to prevent or lessen a serious and imminent    \t\t      \tthreat to the health or safety of a particular person or the general public.\n\n17.\tProof of Immunization. We will disclose proof of immunization to a school where \t\t   \t\tthe  law requires the school to have such information prior to admitting a student if you \t\t     \t\thave agree to the disclosure on behalf of yourself or your dependent.\n\n18.\tSpecialized Government Functions.  We may disclose your health information for \t\t\t\tmilitary or national security purposes or to correctional institutions or law enforcement \t\t   \t\tofficers that have you in their lawful custody.\n\n19.\t Worker&#039;s Compensation. We may disclose your health information as necessary to \t\t\t\tcomply with worker&#039;s compensation laws. For example, to the extent your care is covered \t\t\tby workers&#039; compensation, we will make periodic reports to your employer about your \t\t\t\tcondition. We are also required by law to report cases of occupational injury \t\t\t  \t\tor occupational illness to the employer or workers&#039; compensation insurer.\n\n20.\tChange of Ownership.  In the event that this medical practice is sold or merged with \t\t\t\tanother organization, your health information\/record will become  the  property  of  the  \t\t\t\tnew  owner, although you will maintain the right to request that copies of your health\t       \t\tinformation be transferred to another physician or medical group.\n\n21.\tBreach Notification. In the case of a breach of unsecured protected health information, we \t\t\twill notify you as required by law. If you have provided us with a current email address, we \t\t\tmay use email to communicate information related to the breach. In some circumstances \t\t\tour business associate may provide the notification. We may also provide notification by \t\t\tother methods as appropriate. [Note: Only use email notification if you are certain it will \t\t\tnot contain PHI and it will not disclose inappropriate information. For   example if   \t\t\t\tyour email address   is &quot;digestivediseaseassociates.com&quot; an email sent with this address \t\t\t\tcould, if intercepted, identify the patient and their condition.]\n\n[Add the following three activities, or any of the three, only if the organization engages or intends to engage in these activities]\n\n22.  \tPsychotherapy Notes.  We will not use or disclose your psychotherapy notes without your prior       \n\twritten authorization except for the following: (1) your treatment, (2) for training our staff, \t       \tstudents and other trainees, (3) to defend ourselves if you sue us or bring some other legal    \tproceeding, (4) if the law requires us to disclose the information to you or the Secretary of HHS   \t       \tor  for  some  other  reason,  (5)  in  response  to  health  oversight  activities  concerning  your  \t       \tpsychotherapist, (6) to avert a serious threat to health or safety, or (7) to the coroner or medical \t       \texaminer after you die. To the extent you revoke an authorization to use or disclose your \t        \tpsychotherapy notes, we will stop using or disclosing these notes.\n\n23.\tResearch.  We may disclose your health information to researchers conducting research  \t\t             \twith respect to which your written authorization is not required as approved by an    \n     Institutional Review Board (IRB) or privacy board, in compliance with governing law.\n\n24.  \tFundraising. We may use or disclose your demographic information, the dates that you \t\t        \t\treceived treatment, the department of service, your treating physician, outcome \t\t \t      \t\tinformation and health insurance status in order to contact you for our fundraising \t\t      \t\tactivities. If you do not want to receive these materials, notify the Privacy Officer listed at \t     \t\tthe top of this Notice of  Privacy Practices and we will stop any further fundraising \t\t\t        \tcommunications. Similarly, you should notify the Privacy Office if you decide you want to \t\t         \tstart receiving these solicitations again.\n\nB.     When This Medical Practice May Not Use or Disclose Your Health Information\n\nExcept as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose,\nyou may revoke your authorization in writing at any time.\n\nC.   Your Health Information Rights\n\n1.\tRight to Request Special Privacy Protections.   You have the right to request restrictions on \tcertain uses and disclosures of your health information by a written request specifying what \tinformation you want to limit, and what limitations on our use or disclosure of that information \tyou wish to have imposed.  If you tell us not to disclose information to your commercial health \tplan concerning health care items or services for which you paid for in full out-of-pocket, we \twill abide  by your request, unless we must disclose the information for treatment or legal \treasons. We reserve the right to accept or reject any other request, and will notify you of our\n      \tdecision.\n\n2.   \tRight to Request Confidential Communications.  You have the right to request that you receive\n\tyour health information in a specific way or at a specific location.  For example, you may ask \tthat we send information to a particular email account or to your work address. We will comply \twith all reasonable requests submitted in writing which specify how or where you wish to \treceive these communications.\n\n3.   \t\tRight to Inspect and Copy. You have the right to inspect and copy your health information, with \tlimited exceptions.   To access your medical information, you must submit a written  request \tdetailing what information you want access to, whether you want to inspect it or get a copy of it, \tand if you want a copy, your preferred form and format.   We will provide copies in  your \trequested form and format if it is readily producible, or we will provide you with an alternative \tformat you find acceptable, or if we can\u2019t agree and we maintain the record in an  electronic \tformat, your choice of a readable electronic or hardcopy format. We will also send a copy to any \tother person you designate in writing. We will charge a reasonable fee which covers our costs for \tlabor, supplies, postage, and if requested and agreed to in advance, the cost of  preparing an \texplanation or summary, as allowed by federal and California law. We may deny your request \tunder limited circumstances.   If we deny your request to access your child&#039;s records or the \trecords of an incapacitated adult you are representing because we believe allowing access would \tbe reasonably likely to cause substantial harm to the patient, you will have a right to appeal our \tdecision. If we deny your request to access your psychotherapy notes, you will have the right to \thave them transferred to another mental health professional.\n\n4.  \t\tRight to Amend or Supplement.  You have a right to request that we amend your health \tinformation that you believe is incorrect or incomplete. You must make a request to amend in \twriting, and include the reasons you believe the information is inaccurate or incomplete. We are \tnot required to change your health information, and will provide you with information about \tthis medical practice&#039;s denial and how you can disagree with the denial. We may deny your request \tif we do not have the information, if we did not create the information (unless the person or entity \tthat created the information is no longer available to make the amendment), if you would not be \tpermitted to inspect or copy the information at issue, or if the information is accurate and \tcomplete as  is.  If  we  deny  your  request,  you  may  submit  a  written  statement  of  your \tdisagreement with that decision, and we may, in turn, prepare a written rebuttal. You also have \tthe right to request that we add to your record a statement of up to 250 words  \tconcerning anything in the record you believe to be incomplete or incorrect. All information \trelated to any \trequest to amend or supplement will be maintained and disclosed in  \tconjunction with any \tsubsequent disclosure of the disputed information.\n\n5.  \t\tRight to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of \tyour health information made by this medical practice, except that this medical practice does not \thave to account for the disclosures provided to you or pursuant to your written authorization, or  as  \tdescribed  in  paragraphs  1  (treatment),  2  (payment),  3  (health  care  operations), 6 \t\t(notification and communication with family) and 18 (specialized government  functions) of \tSection A of this Notice of Privacy Practices or disclosures for purposes of research or public \thealth which exclude direct patient identifiers, or which are incident to a  use or disclosure \totherwise permitted or authorized by law, or the disclosures to a health oversight agency or law\n\tenforcement official to the extent this medical practice has received notice from that agency or\n\tofficial that providing this accounting would be reasonably likely to impede their activities.\n\n6.         You have a right to notice of our legal duties and privacy practices with respect to your health\n\tinformation, including a right to a paper copy of this Notice of Privacy Practices, even if you\n\thave previously requested its receipt by email. If you would like to have a more detailed \texplanation of these rights or if you would like to exercise one or more of these rights, contact our \tPrivacy Officer \tlisted at the top of this Notice of Privacy Practices.\n\nD   Changes to this Notice of Privacy Practices\n\nWe reserve the right to amend our privacy practices and the terms of this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with the Notice. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment. \n\n[We will also post the current notice on our website, if applicable]\n\nE.    Complaints\n\nComplaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.\n\nIf you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:\n\nRegion IX\nOffice for Civil Rights\nU.S. Department of Health &amp;amp; Human Services\n90 7th Street, Suite 4-100\nSan Francisco, CA 94103\n(415) 437-8310; (415) 437-8311 (TDD) (415) 437-8329 FAX OCRMail@hhs.gov\n\nThe complaint form may be found at  www.hhs.gov\/ocr\/privacy\/hipaa\/complaints\/hipcomplaint.pdf. \nYou will not be penalized in any way for filing a complaint.\n<\/textarea><\/div><\/div><fieldset id=\"field_34_4\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_34_4\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I Agree<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_34_4'><div class='gchoice gchoice_34_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='NOTICE OF PRIVACY PRACTICES'  id='choice_34_4_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_34_4_1' id='label_34_4_1' class='gform-field-label gform-field-label--type-inline'>NOTICE OF PRIVACY PRACTICES<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_34_10\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  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