NOTICE OF PRIVACY PRACTICES

DATE:

I acknowledge that I was provided with a copy of the Notice of Privacy Practices, Office Policy and Financial Policy.

Patient Name:

If completed by a patient’s Guardian, please print and sign your name in the space below

Guardian’s Name:

Relationship:

For Magical Smiles use only

Complete this section if this form in not signed and dated by the patient or patient’s guardian. I have made a good faith effort to obtain a written acknowledgement of receipt of Magical Smiles Notice of Privacy Practices but was unable to for the following reason:

Patient refused to sign

Patient unable to sign

Other

If other, please specify:

Employee Name:

Date:

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