Acknowlegement of Receipt of Notice of Privacy Practices

have received a copy of this Office's Notice of Privacy Practices.

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For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

©2002 American Dental Association All Rights Reserved 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)