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Madison Pediatrics

Notice of Privacy Practices for Protected Health Information Form

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Notice of Privacy Practices for Protected Health Information

Notice of Privacy Practices from Madison Pediatrics, explaining use and disclosure of patient health information.

Click the image to see a PDF of our Privacy Policy

Acknowledgement of Receipt of Notice of Privacy Practices for PHI

By signing below and submitting, I am acknowledging that I have received Madison Pediatrics' Notice of Privacy Practices for Protected Health Information above. I understand that my child's protected health information may be used by Madison Pediatrics as described in the notice.

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