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A S H E V I L L E N E U R O L O G Y S P E C I A L I S T S, P. A.
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Of Notice of Privacy Practices
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I have received a copy of the Notice of Privacy Practices for the above named practice.
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Signature Date
For Office Use Only
We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:
q An emergency existed & a signature was not possible at the time.
q The individual refused to sign.
q A copy was mailed with a request for a signature by return mail.
q Unable to communicate with the patient for the following reason:
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q Other:________________________________________________
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Prepared By __________________________________________
Signature __________________________________________
Date __________________________________________