Acknowledgement of Receipt of Notice of Privacy Practices

Please correct the errors described below.

I acknowledge that I have been offered a copy of Jeffersonville Common Dental’s Notice of Privacy Practices, which has an effective date of 06/01/2020 and which describes how my health information may be used and disclosed.

I understand that you have the right to change the Notice of Privacy Practices at any time, that I will be provided a copy of any updated version, and that I may contact you at any time to request a current Notice of Privacy Practices.

My signature below acknowledges that I have been provided with a copy of the 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.

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

Your information will be encrypted.

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