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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I, have received a copy of Toga Dental (Patient) Associates Notice of Privacy Practices: Name of Patient or Parent×Guardian (Please Print)
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Start by entering the date at the top of the acknowledgement of receipt form. This is the date when the receipt is being acknowledged.
02
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In the "Receiver" section, fill in the name and contact information of the person or organization who is receiving the acknowledgment. This may include their name, title, address, email address, and phone number.
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