LOADING...  Please wait.
 
Pediatric Dentistry of Forsyth
 

 
* You May Refuse to Sign This Acknowledgment *
 
I have received a copy of this office’s Notice of Privacy Practices.
 
*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)

 

 

 
Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is for general reference purposes only and does not constitute legal advice. It covers only HIPAA, not other federal or state law. Changes in applicable laws or regulations may require revision. Dentists should contact qualified legal counsel for legal advice, including advice pertaining to HIPAA compliance, the HITECH Act, and the US. Department of Health and Human Services rules and regulations.

© 2010, 2013 American Dental Association. All Rights Reserved.
 
Reset 
Powered by Elbowspace.com