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Chart Login Forgot Password? REMEMBER ME {{errorFeedback}} {{r.practiceName}} Logout Download iPhone app to easily manage messaging with your provider {{patient.fName}} {{patient.lName}} Provider Contact {{provider.practiceName}} {{provider.title}} {{provider.streetAddress}} {{provider.city}} {{provider.state}} {{provider.practiceZIP}} {{provider.practicePhone}} Special Instructions {{provider.specialInstruction}} Upcoming Appointments ..updating... No Appointments {{a.apDateDisplay}} {{a.apstart}} {{a.recurrence}} cancel ...working... Request Appointment Change Password Current Password New Password Confirm New Password {{error}} Change Med History Submitted -- Messages {{messageCount}} {{provider.patientNotice}} {{feedback}} ••• Send {{nM.attachmentName}} {{m.posted | date:'shortDate'}} {{provider.practiceName}} {{provider.title}} {{m.message}} {{m}} -- Self Reporting PHQ9 GAD7 PCL5 dsm5 DSM5 Done [ PHQ9 New Score ] [ GAD7 New Score ] Past Medical History [Done] Past Medical History [Please Fill In] Allergies Current Medications Past Medications Past Psychiatric History Save Contact info Dependent Please fill the School/Guardian Section First Name Last Name Email Cell Phone Home Phone Office Phone Select Preferred select preferred phone Cell Home Office Gender Self Described Female Male Date Of Birth Address Address cont City State Zip Code Emergency Contact Emergency Contact Save School and Guardians Guardian 1 Relationship Name Email Address Phone Other Guardian 2 Relationship Name Email Address Phone Other School School Contact Save Other Providers/Contacts Please add all providers, and check box for those you wish to authorize your provider to contact. View Release of Information. Authorization for {{provider.practiceName}} {{provider.title}} to Use or Disclose My Health Information You may use or disclose all my health information (including mental health and substance abuse treatment records) maintained by {{provider.practiceName}} {{provider.title}} to [other provider] at my request, for the purpose of coordination or transfer of treatment. I also authorize [other provider] to release my health information (including mental health and substance abuse treatment records) to {{provider.practiceName}} {{provider.title}} for the purpose of coordination and transfer of treatment.This authorization ends when I end my treatment with {{provider.practiceName}}. My Rights: I understand that I do not have to sign this authorization in order to get health care benefits (treatment). I understand I have a right to a copy of this authorization (available electronically on my patient portal). I may revoke this authorization in writing. If I did, it would not affect any actions taken by {{provider.practiceName}} based upon this authorization. Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it. Ok Add Provider {{p.fName}} {{p.name}} {{(p.type)?p.type:p.specialy}} I have read and agree to Release Of Information Pharmacies {{updating}} not configured {{ph.SearchString}} {{ph.phonePrimary}} {{ph.defaultPharmacy | checkmark1state}} Pharmacy Type Search {{pharmacyType}} Search Mail Order {{c.searchString}} {{c.phonePrimary}} {{p.searchString}} Required Forms I have read and agreed to {{f.formtitle}} on {{f.dateSigned}} Account Recent Statements {{s.from}} - {{s.to}} Credit Card {{ccStatus}} Credit Card On File ending in {{p.CardNumber}} Billing Address Same as Home Save {{errorFeedback}} Balance: {{balance | currency}} {{t.dateAccrued | date: 'shortDate'}} {{t.CPTCode}} {{t.paymentType}} {{t.checkNumber}} {{t.charge | currency: '$'}} {{t.duration}} mins at {{t.rate}} $/hour {{t.comment}} stripe Sign in if you already have an account Welcome to {{newreg.provname}} {{newreg.provname}} is accepting new patients. To book an appointment please register below. Register {{errorFeedback}} Find your provider and click RESET close Find My Provider We texted your temporary password to the phone number on file. OK ..working.. 1 Provider {{providers.length}} Providers {{p.practiceName.substring(0,2)}}**** RESET {{p.retrieveError}} {{p.statusSuccess}} Please contact your provider if you have trouble logging in ©EMPS LLC...