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HI
PAA
PR
I
VA
CY
FOR
M
2
Acknowledgement
of
Receipt
of
Notice
of
Privacy
Practices
P
urpose:
This
form
is
used
to
obtain
acknowledgement
of
receipt
of
our
Notice
of
Privacy
Practices
or
to
document
our
good
faith
effort
to
obtain
that
acknowledgement.
?
2002
American
Dental
Association
All
Rights
Reserved
Reproduction
and
use
of
this
form
by
dentists
and
their
staff
is
permitted.
Any
other
use,
duplication
or
distribution
of
this
form
by
any
other
party
requires
the
prior
written
approval
of
the
American
Dental
Association.
This
Form
is
educational
only,
does
not
constitute
legal
advice,
and
covers
only
federal,
not
state,
law
(August
14,
2002).
H
I
P
A
A
P
R
I
V
A
C
Y
F
O
R
MS
65
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