Dr. Tim Holcomb, DC, NMD, RPh 2601 N. Azalea St. Suite 31 Victoria, TX 77901 HIPPA DECLARATION The effective date of his notice is the date of signature below or the date of the first visit to this clinic. If you have any questions about this notice, please contact the following person: Tamara Holcomb at 361-‐485-‐0449. PATIENT ACKNOWLEDGEMENT By subscribing my name below, I acknowledge receipt of this notice, and my understanding and my agreement to its terms. ___________________________________ ___________________ PATIENT SIGNATURE Date Patient Refused to sign Patient unable to sign for the following reason:________________________________
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