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ACKNOWLEDGMENT OF RECIPT OF NOTICE OF PRIVACY PRACTICES
Purpose: This form is used of obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.

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I, Name , have received a copy of this office's Notice of Privacy Practices.
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Authorization of Release Information
Purpose: This form is used to obtain authorization to release information regarding yourself covered under the Privacy Act to people other than yourself.
I, Name , authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself.
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We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
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2002 American Dental Association
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ACKNOWLEDGMENT OF RECIPT OF NOTICE OF PRIVACY PRACTICES