I, hereby acknowledge that I have received and reviewed a copy of SIMERDEEP GILL, DDS
HIPAA Notice of Privacy Practices.

I understand that SIMERDEEP GILL, DDS HIPAA Notice of Privacy Practice may change periodically and that I am entitled to receive a copy of SIMERDEEP GILL, DDS revised HIPAA Notice of Privacy Practices upon request.

I understand that, if I have questions about SIMERDEEP GILL, DDS. HIPAA, I may contact the Receptionist.

I understand that it is my right to refuse to sign this Acknowledgement and should I so choose, and that SIMERDEEP GILL, DDS, will not refuse treatment to me if I refuse to sign this Acknowledgement.

I further understand that I may contact the Secretary of the U.S. Department of Health and Human Services, should I have concerns regarding SIMERDEEP GILL, DDS, privacy policies and procedures. For more information on how to contact the U.S. Department of Health and Human Services, please ask the receptionist, noted above, for assistance.