TERRY J GILLESPIE, DDS

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.

            _________________________________________________________

            Please Print Name

            _________________________________________________________

            Signature

            _________________________________________________________

            Date

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)