Stephen A. Benson, D.P.M.

ACKNOWLEDGEMENT OF RECEIPT

OF

NOTICE OF PRIVACY PRACTICES

I ACKNOWLEDGE THAT I WAS PROVIDED A COPY OF THE NOTICE OF PRIVACY PRACTICES AND THAT I HAVE READ OR HAD THE OPPORTUNITY TO READ IT IF I SO CHOOSE AND UNDERSTOOD THE NOTICE.

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PATIENT NAME (PLEASE PRINT)

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(DATE)

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PATIENT SIGNATURE

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PARENT OR AUTHORIZED REPRESENTATIVE