Onsite Dental Care - Acknowledge HIPAA

OnSite Dental Care of New England

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 the acknowledgement

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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.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).