shenlingdds..com - Jades Family Notice of Privacy Practices

JADES FAMILY DENTISTRY - ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**
I, Name , have received a copy of this office’s Notice of Privacy Practices.
Name:

First NameLast Name
Signature:

Clear
Date:

MonthDayYear
Date
© 2002 American Dental Association

All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication of 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).
Should be Empty:

JADES FAMILY DENTISTRY - ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES