*Printable Acknowledgement of Receipt of Notice of Privacy Practices *Notice of Privacy Practices *You May Refuse to Sign This Acknowledgement* I have received a copy of this office's Notice of Privacy PracticesName First Middle Last By filling in this section you are agreeing that you have received a copy of this office's Notice of Privacy Practices. *Name of parent/legal guardian, if minorRelationshipIf parent or legal guardian Patient Birthdate MM slash DD slash YYYY Date MM slash DD slash YYYY *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: Individual refused to sign Communication barriers prohibited obtaining acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) CAPTCHA Δ