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.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.