Dr Esmail Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

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I, insert name here, have received a copy of this office’s Notice of Privacy Practices.
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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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Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or 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).
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Acknowledgement of Receipt of Notice of Privacy Practices