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Please provide responsible party personal information and login credentials.

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By checking this box, I acknowledge that I have read and understood the Terms of Service, Privacy Policy and HIPAA Authorization. I consent to the electronic disclosure and use of my protected health information (PHI) in accordance with HIPAA regulations, and I agree to the collection, use, and sharing of my personal health information as outlined. I understand that I can revoke this authorization at any time by following the steps described in the policy.

I agree to the terms of the E-Sign Act Disclosure Agreement. I acknowledge that by checking this box, I consent to the use of electronic records and signatures in place of physical documents, and that I have read and agree to the terms outlined in the E-Sign Act Disclosure Agreement.

I agree to the terms of the Uniform Electronic Transactions Act (UETA) Agreement. By checking this box, I consent to the use of electronic records and signatures in place of physical documents, and I acknowledge that I have read, understand, and agree to the terms outlined in the UETA Agreement.

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