Acknowledgement of Receipt of HIPAA Notice of Privacy Practices (“Acknowledgement”)

By signing below, I acknowledge that I have received a copy of Happy Teeth Dental Care’s HIPAA Notice of Privacy Practices.

Patient/Personal Representative Signature:

Authority of Personal Representative to Sign for Patient (check one):

*Please Note: it is your right to refuse to sign this acknowledgement.

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© 2020 Happy Teeth Dental Care, PC

Happy Teeth Dental Care

135 Boston Turnpike 

Shrewsbury, MA 01545

Office Phone Number: (508) 425-3316

Office Fax Number: (508) 753-3318