HIPAA – Amador Dentistry

Amador Family Dentistry, PLLC

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF

PRIVACY PRACTICES

*You May Refuse To sign This Acknowledgement
Name
First
Have been informed of this office H.I.P.A.A compliance, Notice of Privacy Practices.
Sign Here (If age 18 or over)
(If signing for someone under the age of 18 list relationship and name of patient)
(If signing for someone under the age of 18 list relationship and name of patient)
Today's Date
Date Format: MM slash DD slash YYYY

Today's 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
*This form is educational only, does not constitute legal advice, and covers only federal law, not state law ( August 14,2002)