Acknowledgment of Receipt of Notice of Privacy Practices

Hilton Progressive Dental

I acknowledge that I have been provided a copy of Hilton Progressive Dental’s Notice of Privacy Practices, which has an effective date of 09/15/2016, and which describes how my health information may be used and disclosed. I understand that you have the right to change the Notice of Privacy Practices at any time, that I will be provided a copy of any updated version, and that I may contact you at any time to request a current Notice of Privacy Practices. My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:

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Signature of Patient or Patient’s Representative

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