patient name :

date :

information may be additionally released to:

i have received/reviewed a copy of this officer's notice of privacy practices.

Signature of patient /parent or Guardian (if under age 18)

we attempted to obtain written aknowledgement of receipt of our notice of privacy practices. however acknowledgement could not to obtain because:

individual refused to sign:

communication barriers prohibited obtaining:

other(specify):

Acknowledgement of receipt of notice privacy practices