By submitting this HIPAA Compliant Secure Form, I am giving permission
to Dr. Amy Fuller and her office staff to contact me or those listed above
with the information provided. I am aware that email, telephone and text
are not secure, private methods of communication.
YOUR PRIVATE HEALTH INFORMATION WILL BE KEPT COMPLETELY CONFIDENTIAL.
Any insurance information provided will be for the sole purpose of determining
eligibility of benefits for therapy.