Acknowledgement of Receipt of Notice of Privacy Practices


(916) 817-2649




I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices.  I further acknowledge that a copy of the current notice will be available in the reception area, available on the practice website (, and that a copy of any amended Notice of Privacy Practices will be made available upon request at each appointment.



Signed: ______________________________     Date: __________________________

Print Name:  __________________________     Telephone: _____________________

If not signed by the patient, please indicate relationship:


                      ¨    parent or guardian of minor patient

                      ¨    guardian or conservator of an incompetent patient



Name and Address of Patient: _________________________________________






Signature not obtained: 

       ______        Patient unable to sign


       ______        Patient unwilling to sign


       ______        Notice mailed to patient, signature pending



________________________________________                                 _________________

Name of Practice Representative                                                               Date







Notice of Privacy Practices Acknowledgments Tracking Information

Name of Patient:  _______________________________________________________

Address:  ______________________________________________________________



For Office Use Only:

Date received:

Processed by:

Practice Follow-up:  ٱ  Yes  ٱ  No

Date of Practice Follow-up:


Complete the following only if the Patient refuses to sign the Acknowledgment:


Efforts to obtain:





Reasons for refusal: