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Acknowledgement of Notice of Receipt of Privacy Practices:
Download the Acknowledgement of Receipt of Notice of Privacy Practices here
(24K)
Richard C. Yung, D.D.S.
1140 St. Andrews Road
Columbia, South Carolina 29210
Tel. (803) 798-3204
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgement**
I, ____________________________________, have received a copy of this office’s Notice of Privacy Practices.
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{Please Print Name}
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{Signature}
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{Date}
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
- Individual refused to sign
- Communications barriers prohibited obtaining the acknowledgement
- An emergency situation prevented us from obtaining acknowledgement
- Other (Please Specify)
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