Dr. Donald L. Taylor, Jr. D.D.S.

ACKNOWLEDGMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgment*

   I,_________________________________________have reviewed or received a copy of this office’s Notice of Privacy Practices.

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             Please Print Name Here

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             Signature

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             Date

   This office may release information to the named persons;

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______________________________________________________________________________________________________   For Office Use Only

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We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices but acknowledgment could not be obtained because:

           [] Individual refused to sign.

           [] Communication barriers prohibited obtaining the acknowledgment.

           [] An emergency situation prevented us from obtaining acknowledgment.

           [] Other (Please Specify)

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