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Madison Pediatrics



Notice of Privacy Practices for Protected Health Information Form - Update

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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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(Type your first and last name.)
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By signing this form (typed signature), you are certifying the accuracy of this information and agreeing to send the information to Madison Pediatrics, Inc., for inclusion into your child's records.
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