Dr. Michael Ayzin’s Dental Office
Acknowledgement of Receipt of Notice of Privacy Practices
Purpose: This form is used to obtain
acknowledgement of receipt of our Notice of Privacy Practices or
to document our good faith effort to obtain that 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 (check
one):
( ) Individual refused to sign
( ) Communications barriers prohibited obtaining the
acknowledgement
( ) An emergency situation prevented us from obtaining
acknowledgement
( ) Other (Please Specify)
______________________________________________________________________________
______________________________________________________________________________
© 2002 American Dental Association
All Rights Reserved
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 (
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Last Modified: April 25, 2003