Chris T. Nhan, D.D.S.

Acknowledgement of receipt of HIPAA notice of privacy practices
("Acknowledgement")

I acknowledge that I have receieved a copy of this Dental Practice's HIPAA Notice of Privacy Practices.

OR

Authority of Personal Representative to Sign for Patient (check one):

Please note: It is your right to refuse to sign this Acknowledgement.

Dental Office Use Only

I tried to obtain a written Acknowledgement by the indivdual noted above of receipt of our Notice of Privacy Practices, but it could not be obtained because: