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Park Cities Periodontics & Implant Dentistry ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgment** I have received a copy of these offices NOTICE

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What is you may refuse to?

You may refuse to provide certain personal information.

Who is required to file you may refuse to?

Anyone who is mandated to report such information.

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You can fill out the form online or submit a physical copy by mail.

What is the purpose of you may refuse to?

The purpose is to protect individuals' privacy and right to refuse certain disclosures.

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Any information that the individual wishes to withhold.

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