Acknowledgement of Receipt of Notice of Privacy Practices Form

* You may refuse to sign this Acknowledgement

I, _____________________________, have received a copy of this office’s Notice of Privacy Practices.

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Please Print Full Name

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Signature

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Date

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

__ Individual refused to sign

__ Communications barriers prohibited obtaining the acknowledgement

__ An emergency situation prevented us from obtaining acknowledgement

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