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Acknowledgement of Receipt Notice of Privacy Practices Privacy Officer: Valeria M. Ware ham, Executive Director pH: (831) 3754105 By signing this form, you acknowledge receipt of the Notice of Privacy
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Patients or clients who receive services from RJ Stevenson DDS are required to file the acknowledgment of receipt, confirming they have received pertinent information regarding their treatment.
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To fill out the acknowledgment of receipt, individuals must provide their personal information, date of receipt, and sign the document to confirm that they have received the specified materials.
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The purpose of the acknowledgment of receipt document is to provide proof that patients have received and understood important information regarding their dental care or treatment plans.
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The acknowledgment must report the recipient's name, date, description of the materials received, and the recipient’s signature.
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