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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I, have received a copy of these offices Notice of Privacy Practices. (Please Print Name)

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4. If necessary, seek legal advice or consult with relevant experts to understand the potential impact of your refusal. They can provide guidance on the legal implications, risks, and potential alternatives.
5. When filling out the document or form, locate the section or checkbox specifically provided for the option to refuse. Follow any specific instructions given in that section.
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8. Keep a copy of the filled-out form or document for your reference. It is essential to have a record of your refusal in case any disputes or issues arise later.

Who needs you may refuse to:

1. Individuals who want to exercise their right to refuse certain obligations or requests.
2. Employees who may be offered certain tasks or responsibilities that they are not willing or able to carry out.
3. Contractors or service providers who have the option to refuse certain projects or tasks based on their contracts or agreements.
4. Individuals who have moral, ethical, or religious objections to specific actions or requests.
5. Individuals who want to protect their personal rights, privacy, or interests by refusing certain demands or requirements.

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