I certify that I have received a copy of DFW Orthotics and Prosthetics Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of bills or in the performance of DFW Orthotics and Prosthetics health care operations. The Notice of Privacy Practices also describes my rights and DFW Orthotics and Prosthetics duties with respect to my protected health information. The Notice of Privacy Practices is posted in 1721 W. Plano Pkwy Ste 212, Plano, TX 75075 and on DFW Orthotics and Prosthetics website at www.dfwop.com.

DFW Orthotics and Prosthetics reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy to be sent in the mail, asking for one at the time of my next appointment or accessing DFW Orthotics and Prosthetics website.

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By signing below, I authorize the payment of medical benefits to DFW Orthotics and Prosthetics once the services are rendered from DFW Orthotics and Prosthetics.