I am required to provide you with a copy of my Notice of Privacy Practices, which states how I may use and/or disclose your health information.

Please sign this form to acknowledge receipt of the Notice of Privacy Practices.

You may refuse to sign this acknowledgement, if you wish.

I acknowledge that I have received a copy of the office’s Notice of Privacy Practices.

Full Name *

Signature *

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Date of Signature *

If the Above Is Not Signed, This Lower Section Should Be Completed by Dr. Singh:

I have made every effort to obtain written acknowledgement of receipt of our Notice of Privacy Practices from this patient but it could not be obtained because:

The patient refused to sign.
Due to an emergency situation it was not possible to obtain an acknowledgement.
I was not able to communicate with the patient.
Other (Please provide specific details)

Dr. Singh Signature

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Date of Signature - Dr. Singh