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Acuse de Recibo de la Notificación de Practicas de Privacidad
*Usted Puede Negar Este Acuse de Recibo*
Yo he recibido una copia de la Notificacíon de Practicas de Privacidad de este consultorio.
Para Uso de la Oficina Solamente (For Office Use Only)

Nosotros intentamos obtener reconocimiento de recibo del Aviso de Practicas de Privacidad por escrito, pero el reconocimiento no pudo ser obtenido porque: (We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:)

Individuo(a) se nego a firmar (Individual refused to sign)
Barreras de communicación no permitieron obtener el reconocimiento (Communications barriers prohibited obtaining the acknowledgement)
Una situación de emergencia evito obtener el reconocimiento (An emergency situation prevented us from obtaining acknowledgement)
Otro (Por favor especifique) (Other {Please specify})
Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is for general reference purposes only and does not constitute legal advice. It covers only HIPAA, not other federal or state law. Changes in applicable laws or regulations may require revision. Dentists should contact qualified legal counsel for legal advice, including advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations.
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