testing 20 June Step 6admin2023-06-22T10:24:18+00:00 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESI acknowledge that I have received a copy of the Amarillo Bone & Joint Clinic, LLP (AB&JC) Notice of Privacy Practices.Patient Signature Date MM slash DD slash YYYY Patient Legal Representative (if applicable) Date MM slash DD slash YYYY Print name of Legal Representative Relationship to patient Textarea Textarea FOR AB&JC USE ONLYAB&JC has made the following good faith efforts to obtain the above-referenced individual's written acknowledgement of receipt of the Notice of Privacy Practices: (Identify the efforts that were made to obtain the individual's written acknowledgement, including the reasons (if known) why the written acknowledgement was not obtained.) Textarea Textarea Textarea Name of Office Representative Date Placed in Patient Chart
