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Acknowledgment of Privacy Practices

  • Acknowledgement of Privacy Practices

  • I hereby acknowledge that I have received a copy of the Notice of Privacy Practices from Nease & Higginbotham Orthodontics, PA.

    I have listed individuals that are authorized to receive my protected health information. I am aware that I can revoke the authorization for any individual at any time, but most do so in writing.

  • (required if patient is minor or an adult unable to sign form)
  • The following individuals have my authorization to access my Protected Health Information




Acknowledgment of Privacy Practices