ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

I, _______________________________________________, have received a copy of this office’s
Notice of Privacy Practices.

______________________________________________
{Please Print Name}

______________________________________________
{Signature}

______________________________________________
{Date}

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:

     Individual refused to sign

     Communications barriers prohibited obtaining acknowledgement

     An emergency situation prevented us from obtaining acknowledgement

     Other (Please Specify)

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

© 2002 American Dental Association