Acknowledgement of Receipt of Notices of Privacy Practices

Dentkos Endodontics
*You May Refuse to Sign This Acknowledgement*

A copy of this office’s Notice of Privacy Practices was made available to me.

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
An emergency situation prevented us from obtaining acknowledgement
Other (Please specify below)

Other (Please specify)