Patient Request for Restrictions on Use and Disclosure of PHI Patients should complete this form when requesting all or part of his/her PHI be
restricted to use within your practice, or through disclosure to outside entities. The patient provides specific information on what to restrict and from whom, allowing you to record when/how the request is granted, denied and/or terminated. Retain in patient’s medical record.

FREIGHT CHARGES
ACS always confirms to our customers total amount to be charged including freight costs before order
is processed.

RETURNS
There is a 15 day return policy. Customers have 15 days to return products after they have received them. Products are not returnable after this time. Returns are subject to a restocking fee of 25%. If the return is a result of our error, we will issue a call tag. We grant returns on products only if the product and the packaging are in re-sellable condition. Custom products are not returnable.

SALES TAX
ACS charges sales tax if you are a Texas resident, Texas State Sales Tax will be added at the time your
order is invoiced. If you are tax exempt you must provide a Texas Sales Tax Exemption Certificate.