Acknowledgment of Receipt of Notice of Privacy Practices
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Yes, I have been informed of this office's Privacy Practices.
No, I refuse to sign this acknowledgement of the office's HIPAA Privacy Practices.
Patient's First and Last Name
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First Name
Last Name
Email address
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Today's Date
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Day
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Signature Required. Parent or Guardian signature required if under 18. (if not signed we will have you do a paper copy if office)
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