HIPPA POLICY FORM
Acknowledgement of Receipt of Notice of Privacy Practices You May Refuse to Sign this Acknowledgement
I  ___________________, have received a copy of this office's            (please print name)                              Notice of Privacy Practices.  ______________________________________  Signature   ______________   Date
For Office Use Only We attempted to obtain written acknowledgement of our receipt of our Notice of Privacy Practices, but acknowledgement could not be attained because: Individual refused to sign communication barriers prohibited obtaining the acknowledgement an emergency situation prohibited us from obtaining acknowledgement other  _________________________________________________

Patrick F. Ballard DMD, PC