Acknowledgement of Receipt of HIPAA Notice of Privacy Practices

Please correct the errors described below.

Hereby acknowledge that I have received and reviewed a copy of ADIC's HIPAA Notice of Privacy Practices.

I understand that ADIC's HIPAA Notice of Privacy Practices may change periodically and that I am entitled to receive a copy of ADIC's revised HIPAA Notice of Privacy Practices upon request.

I understand that, if I have questions about ADIC's HIPAA Notice of Privacy Practices, I may contact Dr. Harry Ashitey at 940-489-8181

I understand that it is my right to refuse to sign this Acknowledgement should I so choose and that ADIC will not refuse treatment to me if I refuse to sign this Acknowledgement.

I further understand that I may contact the Secretary of the U.S  Department of Health and Human Services should I have concerns regarding ADIC's privacy policies and procedures. For information on how to contact the U.S. Department of Health and Human Services, please ask Dr. Harry Ashitey, noted above, for assistance.

For Office Use Only

Aesthetic Dentistry and Implant Center made a good-faith effort to obtain Acknowledgement, from the patient noted above, of receipt of its HIPAA Notice of Privacy Practices. In spite of these efforts, Aesthetic Dentistry and Implant Center was unable to obtain a signed Acknowledgement for the following reason(s):

Communications barriers prohibited us from obtaining a signed Acknowledgement.

An emergency situation prohibited us from obtaining a signed Acknowledgement.

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