Acknowledgment of Receipt of Notice of Privacy Practices

Please correct the errors described below.

5802 Nolensville Pike, Suite 103
Nashville, TN 37211
Phone-615-873-4495
Fax-615-873-4436

7106 Moores Lane
Brentwood, TN 37027
Phone-615-540-1184
Fax-615-873-4436

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Dr. Harry Mack or Dr. Ryan Thomas at our office.

Purpose: This form is used to obtain acknowledgment of Receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgment.

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

You May Refuse to Sign This Acknowledgement

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

AUTHORIZATION TO RELEASE INFORMATION

Purpose: This form is used to obtain authorization to release information regarding yourself covered under the Privacy Act to people other than yourself.

authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself.

Add Additional Authorized Person(s)

FOR OFFICE USE ONLY

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

NASHVILLE ORAL SURGERY

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