HIPAA Notice Receipt Form - Andros Orthodontics | Tri Cities Orthodontics

**Please read our Notice of HIPAA Privacy Practices before filling out the form below.**

You may fill out the Acknowledgement of Receipt of Notice of Privacy Practices online and submit it to our office, or download, print, and fill out a PDF copy of the form to bring with you to your next appointment.

Download PDF – HIPAA Notice Receipt Form

Acknowledgement of Receipt of Notice of HIPAA Privacy Practices

**You May Refuse to Sign This Acknowledgement**

Patient Name*
Patent Email*
Patient Phone Number*
Please check one:*
- I have received a copy of this office's Notice of Privacy Practices.
- I have chosen not to sign this acknowledgement.
Your Name*
Date*
Relationship to Patient*

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