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 acknowledge that I have received a copy of Dental Health Professional’s Notice of Privacy Practices:
Please Print Name
Date
Signature
Please list the names of your family members or any other person that has your permission to have access to your personal health and account information:
Name 1
Relationship 1
Name 2
Relationship 2
Name 3
Relationship 3
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