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Acknowledgement of Receipt of Notice of Privacy Practices
I have received a copy of the Notice of Privacy Practice for Hoyle Family Dentistry.

Signature Pad

THE REST IS FOR OFFICE USE ONLY

We were unable to obtain a signed receipt of the Notice of Privacy Practices because:
  • An emergency existed & a signature was not possible at the time
  • The individual refused to sign
  • A copy was mailed with a request for a signature by return mail
  • Unable to communicate with the patient for the following reason:
  • Other reason
Prepared by (staff):  
Staff member's Signature:
Date:
Done