ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
**You may refuse to Sign this Acknowledgement**
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices this day of date.
A copy of this signed and dated Acknowledgement shall be as effective as theĀ original.
Thank you, and if you have any questions about this form or the attached Notice, please see our Front Desk Staff.