PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES FORMS

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PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Full Name:

I, [full name], have received a copy of the Empire Endodontics Notice of Privacy Practices or have been given direction on how to obtain a copy online.

Print Name:

Signature:

If this acknowledgement is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative's Name:

Relationship to Patient:

PATIENT FOR PROGRAM USE ONLY

Patient Name:

Date:

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

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Other:

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Patient Forms

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES FORMS

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES FORMS

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, [full name], have received a copy of the Empire Endodontics Notice of Privacy Practices or have been given direction on how to obtain a copy online.

If this acknowledgement is signed by a personal representative on behalf of the patient, complete the following:

PATIENT FOR PROGRAM USE ONLY

Empire Endodontics

1881 Business Center Dr S, San Bernardino, CA 92408

OFFICE HOURS

1881 Business Center Dr S, San Bernardino, CA 92408

909-383-8931

frontoffice@endoisfun.com

Patient Forms

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES FORMS

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES FORMS

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, [full name], have received a copy of the Empire Endodontics Notice of Privacy Practices or have been given direction on how to obtain a copy online.

If this acknowledgement is signed by a personal representative on behalf of the patient, complete the following:

PATIENT FOR PROGRAM USE ONLY

Empire Endodontics

1881 Business Center Dr S, San Bernardino, CA 92408

OFFICE HOURS

1881 Business Center Dr S, San Bernardino, CA 92408

909-383-8931

frontoffice@endoisfun.com

We value your privacy