The Independent Practices of RALEIGH OPHTHALMOLOGY
Fax: 919-782-1680
Acknowledgement of Receipt of
Notice of Privacy Practices
Please complete and return to the office or fax to the office at 919-782-1680
Patient Name _______________________________________
Address ____________________________________________________________
City, State, ZIP ____________________________________________________________
I have a received a copy of the Notice of Privacy Practices for the above named practice.
Signature _______________________________
Date _____________________
Below For Office Use Only
We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:
__ An emergency existed & a signature was not possible at the time.
__ The individual refused to sign.
__ A copy was mailed with a request for a signature by return mail.
__ Unable to communicate with the patient for the following reason:
_____________________________________________________
