HIPAA ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.


**You May Refuse to Sign This Acknowledgement**

 

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


Full Name:
Date:
Signature:

 

Please print this form and bring it with you to your appointment

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© 2002 American Dental Association, All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

 
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