Privacy Practices Form

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY POLICY

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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 parties requires the prior written approval of the American Dental Association.

This form is for education 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 POLICY