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PATIENTS ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY RULES I, have received a copy of the Notice of the privacy Practices of Smiles On Class. I decline to sign the Acknowledgement. OPTING OUT:

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What is patients acknowledgement of receipt?

Patients acknowledgement of receipt is a document signed by a patient confirming they have received a copy of their medical records.

Who is required to file patients acknowledgement of receipt?

Healthcare providers are required to file patients acknowledgement of receipt.

How to fill out patients acknowledgement of receipt?

Patients acknowledgement of receipt can be filled out by including patient's name, signature, date of receipt, and healthcare provider's information.

What is the purpose of patients acknowledgement of receipt?

The purpose of patients acknowledgement of receipt is to ensure patients have received a copy of their medical records for their own records or to share with other healthcare providers.

What information must be reported on patients acknowledgement of receipt?

The information reported on patients acknowledgement of receipt should include patient's name, date of receipt, signature, and healthcare provider's information.

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