Acknowledgement of Receipt of Notice of Privacy Practices I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I acknowledge that I have received, reviewed, or been offered a copy of Pagan Orthodontics’ Notice of Privacy Practices, which provides a complete description of how my health information may be used or disclosed, and how I can access this information. I understand that the practice has the right to change its Notice of Privacy Practices at any time and that I may obtain a revised copy by contacting the Privacy Officer at Pagan Orthodontics. I also understand that I may request restrictions on how my information is used or disclosed, but that the practice is not required to agree to these restrictions.