Acknowledgment of Receipt | The Denture Specialist

Acknowledgement of Receipt

We are required to provide you with a copy of our Notice of Privacy Practices which states how we may use and/or disclose your health information.
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By signing this form, I acknowledge that I have signed and received a copy of this office's Notice of Privacy Practices for my records.
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I also acknowledge that I have signed and received a copy of the Financial Arrangements/Insurance Authorization & Billing Information for my records.
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I understand that signed copies of these forms have been scanned into my digital chart for documentation purposes.
Patient Name*
First Last
Signature of Patient, Parent or Guardian*
Email
This field is for validation purposes and should be left unchanged.

Acknowledgement of Receipt