Acknowledgement of Receipt Of Notice of Privacy Practices

Please correct the errors described below.

I have received a copy of the Notice of Privacy Practices for the above named practice.

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FOR OFFICE USE ONLY

We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because

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.

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