ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, have reviewed a copy of the notices of privacy practies.

Please Print Name

Signature

Date

For Office Use Only

We attempt to obtain written acknowledgement to receipt of our privacy practices,our acknowledgement could not be obtained because:

Individual refuse tosign.

communication barriers prohibited acknowlegement.

An emergency situation prevented us from obtaining acknowledgement.

other(please specify).