HIPPA Acknowledgement Form

Acknowledgment of Receipt of Notice of Privacy Practices

You May Refuse to Sign This Acknowledgement

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for Dr. Steven M. Hall, DMD, P.A A copy of this signed, dated Acknowledgement shall be as effective as the original.

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.

Thank you and if you have any questions about this form or the attached Notice, please contact our privacy officer, at:

Privacy Officer for Steven M. Hall, DMD, PA 252 Plaza Drive Oviedo, FL 32765 Phone: (407)365-1242 Fax:(407)365-4998