Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or decline the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for seven years.
- Patient Name*
  
  First NameLast Name
- Parent, Guardian, or Legal Representative
  
  First NameLast Name
- Signature*
- Date Signed*
  
  MonthDayYear
  Date
- Name
  
  First NameLast Name
- Relationship to Patient
- Name
  
  First NameLast Name
- Relationship to Patient
- Should be Empty:

Acknowledgement of Receipt of Notice of Privacy Practices