*You May Refuse to Sign This Acknowledgement*
I, ______________________________________________,
have received a copy of this office’s Notice of Privacy Practices.
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{Signature}
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{Date}
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For Office Use Only
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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
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©
2002 American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.