Acknowledgement of Review of Notice of Privacy Practices

I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of document.

I have chosen not to review this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed, but I was given the opportunity to do so. I understand that I am entitled to receive a copy of this document.

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            Signature of Patient or Personal Representative

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            Date

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            Name of Patient