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Get the free I acknowledge that I received a copy of Vision Source's Notice of Privacy Practices

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Patient name Signature Date if patient is under age 18 parent or guardian must sign For office use only DATE ACCOUNTING OF DISCLOSURES DISCLOSED TO NAME/ADDRESS PHI DISCLOSED PURPOSE BY. ACKNOWLEDGMENT OF RECEIPT I acknowledge that I received a copy of Vision Source s Notice of Privacy Practices.
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Who needs i acknowledge that i?

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Employees who are required to acknowledge company policies or procedures.
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Contractors who need to confirm their understanding and acceptance of terms.
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Participants in legal agreements or contracts.
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Students or parents acknowledging school policies.
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Individuals participating in official government forms or applications.
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Applicants for various licenses or permits.
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Anyone signing documents that require acknowledgement of specific statements.

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