Patient Acknowledgement of Receipt of Notice of Privacy Practices

DR. LARRY M. WOLFORD – ORAL AND MAXILLOFACIAL SURGERY CLINIC

Patient Name: ___________________________________________________

Date of Birth: ____________________________________________________

 

I acknowledge that Larry M. Wolford, DMD – Oral and Maxillofacial Surgery provided me with a written copy of his/her Notice of Privacy Practices.

I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.

 

Patient Signature: ________________________________________________

Date: ______________________________

Personal Representative Signature: __________________________________

Relationship to Patient: ____________________________________________

 

All articles and any forms, checklists, guidelines and materials are for generalized information only, and should not be reviewed or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. They are intended as resources to be selectively used and always adapted – with the advice of the organization’s attorney – to meet state, local, individual organizations and department needs or requirements.