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Confidentiality Agreement

By submitting this form, you acknowledge and consent to the collection, storage, and use of your health information for the purposes of providing personalized wellness and clinical services.

Please review our HIPAA Notice of Privacy Practices

Confidentiality Agreement

By submitting this form, you acknowledge and consent to the collection, storage, and use of your health information for the purposes of providing personalized wellness and clinical services.

Please review our

HIPAA Notice of Privacy Practices

A Shared Commitment to Care

an important part of your wellness journey

We kindly ask you take a moment to review and sign the agreement to complete this step of your intake process.

At bZengi, we are committed to respecting and protecting your privacy and confidentiality. In some circumstances, we may find it beneficial to consult with other Healing Arts professionals or healthcare providers to support your well-being. Except when disclosure is required or permitted by applicable law, including HIPAA-related legal, regulatory, or compliance obligations, no personal information will be shared without your prior written authorization.


I understand that bZengi fully respects and safeguards my privacy and confidential information. If bZengi determines that discussing my case or sharing relevant information with other Healing Arts professionals or healthcare providers would support my well-being, I agree to provide timely written authorization when requested.


I acknowledge that bZengi will only communicate with or disclose information to other professionals after receiving my written consent, except when disclosure is required or permitted by law, including for HIPAA compliance, legal proceedings, public health reporting, or other authorized purposes. Any disclosure will be limited to the information reasonably necessary to fulfill the applicable purpose and support my care and well-being.

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If this form is being signed by someone other than the client, please type your first and last name below .
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Please indicate your role in signing this agreement :
Client
Parent
Legal Guardian
Caregiver
Authorized Representative
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I acknowledge that I have received and reviewed bZengi’s HIPAA Notice of Privacy Practices. I understand how my protected health information may be used and disclosed, as well as my rights regarding the privacy and confidentiality of my health information.

Please select below :
Yes, I have received and reviewed the HIPAA Notice of Privacy Practices
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