Privacy Practice Form

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Podiatric Medical Partners of Texas, P.A. - Notice of Privacy Practices

WILLIAM C. ARRINGTON, D.P.M. AND ASSOCIATES ARE COMMITTED TO PROTECTING THE PRIVACY AND SECURITY OF INDIVIDUAL IDENTIFIABLE HEALTH INFORMATION AND OTHER PROTECTED HEALTH INFORMATION OF A CONFIDENTIAL NATURE FOR THIS MEDICAL PRACTICE AS SET FORTH IN THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT ("HIPPA"). I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS "NOTICE OF PRN ACY PRACTICES" .

Consent for Release of Information & Medical Records

To Release or Disclose to:

Dr. William Arrington, Dr. Justin Wade, Dr. Raymond Delpak @ BeltIine/Wylie/Forney/Rowlett Foot & Ankle 1601 N. BeltIine Rd. Suite A Mesquite, TX 75149 (Main office) Ph: 972-288-7441 Fax: 972-289-8025

I authorize this information to be release. This consent is subject to revocation at any time by me in writing.

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