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Pes Pdry P.A. Frk J. Csg DPM FACFAS Mhew H. Eherdge DPM FACFAS Dpmes Amer Brd f Pdr Surgery Pe me: The Pre:. Is requred by feder w m he prvy f yur Pers Heh Ifrm PHI d prvde yu wh hs Prvy Ne deg he Pre s eg dues d prvy pres wh respe yur PHI. b. Uder he Prvy Rue my be requred by Se w gr greer ess r m greer resrs he use r reese f yur PHI h h whh s prvded fr uder feder w.. s requred bde by he erms f hs Prvy Ne. d. Reserves he rgh hge he erms f hs Prvy Ne d mke he ew Prvy Ne prvss effeve fr yur ere PHI h ms. e. W dsrbue y revsed Prvy Ne yu prr mpeme. f. W ree gs yu fr fg mp. EFFECTIVE DATE Ths e s effeve s f // PATIENT ACKNOWLEDGMENT By sgg my me bew I kwedge reep f py f hs Ne d my udersdg d greeme s erms. Pr Nme: Sgure: De: N. Dvs Hwy Se N. Dvs Hwy Hwy Pes FL Pes FL M FL - -