By signing below, I acknowledge that I am aware of Bridgepoint’s Notice of Privacy Practices and Individual Rights. We may use or share your medical information with personnel involved in your care at Bridgepoint. We may disclose your medical information to people outside of the system, such as Health Information Exchanges. Bridgepoint’s Notice of Privacy Practices contains more information about the policies and practices protecting the patient’s privacy. I acknowledge that I have read the above, am giving my consent to the above, and am acknowledging I have been informed of my rights to privacy.
Complete this form so we can assist with your mental health journey.