Notice of Privacy Practices Acknowledgement

By signing below, I acknowledge that I have received a written copy of Fine Hearing Care’s Notice of Privacy Practices.

Signature:                                                                                Date:                                       

Printed Name:                                                                        Relationship:                                                         

Address:                                                                                          Phone:                                             

I have attempted to obtain a written acknowledgement for the receipt of Fine Hearing Care’s Notice of Privacy Practices;
however, written acknowledgement could not be obtained due to:

( ) An emergency situation prevented written acknowledgement prior to services rendered.

( ) The patient refused to sign this form of written acknowledgement.

( ) Other:

Signature:                                                                       Date:                                            

Printed Name: