Dr. Michael Ayzin’s Dental Office

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.

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Please Print Name

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Signature

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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)

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© 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 (August 14, 2002).

Last Modified: April 25, 2003