Ali Shirani DDS

3725 Lone Tree Way #F, Antioch, CA 94509

925-778-1998

Acknowledgement of Receipt of Notice Of
Privacy Practices

You May Refuse to Sign This Acknowledgement *

I, ,have received a copy of this office's Notice of Privacy Practices.

Patient Information

E‐mail:

Cellular:

Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Primary Practices, but acknowledge could not be obtained because:

Individual refused to sign

Communication barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

© 2002 American Dental Association
All Right Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.
This Form is education only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

Acknowledgement of Receipt of Notice Of Privacy Practices

Patient Information

Signature:

For Office Use Only

Acknowledgement of Receipt of Notice Of
Privacy Practices