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A. 5228 W. Plano Pkwy Plano TX 75093 Phone 972-250-5700 Fax 972-250-5748 Patient Legal Name DOB SS Address Phone City State Zip Code I Hereby Authorize Plano Orthopedic Sports Medicine and Spine Center P. Authorization for Use and Disclosure of Protected Health Information PHI Plano Orthopedic Sports Medicine Spine Center P. A. Facility or Covered Entity To disclose medical record information and/or Protected Health Information PHI of the patient listed above to Name/Title Purpose For...
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5228 W Plano Pkwy is a physical address located in Plano, Texas.
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