Acknowledgement of Receipt of Notice of Privacy Practices

You May Refuse to Sign This Acknowledgement

have received a copy of the name of practice Notice of Privacy Practices.

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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If this acknowledgement is signed by a personal representative on behalf of the patient, complete the following:

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We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

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