HIPAA Consent Form

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Acknowledgement of Receipt of Notice of Privacy Practices

Please note that you may refuse to sign this acknowledgment. If you choose not to sign, please indicate as such by checking the box below:
- I refuse to sign
I affirm that I have received a copy of Portalupi Orthodontics' Notice of Privacy Practices.
Name (First, Middle, Last)
Signature
Today's Date
MM slash DD slash YYYY
If this acknowledgment is signed by a personal representative on behalf of the patient, please complete the following:
Personal Representative's Name
Relationship to Patient