I have been given a copy of Harry L. Habbel, D.D.S. Notice of Privacy Practices (”Notice”), which describes how my health information is used and shared. I understand that the Practice has the right to change this notice at any time. I may obtain a copy by contacting the Practice Privacy Offier.

My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:

For Facility Use Only: Complete this section if you are unable to obtain a signature

If the patient or personal representative is unable or unwilling to sign this Acknowledgment, or the Acknowledgment is not signed for any other reason, state the reason: