ACKNOWLEDGEMENT OF RECEIPT

OF

NOTICE OF PRIVACY PRACTICES

          I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read

(or had the opportunity to read if I so chose) and understood the Notice.

____________________________                     _______/______/______

Patient Name (please print)                                                                               Date

____________________________

Parent or Authorized Representative (if applicable)

____________________________

Signature

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