Acknowledgement of Receipt of Notice of Privacy Practices

(You may refuse to sign this acknowledgement)

Individual's Name: {{patient_first_name}} {{patient_last_name}} Birthdate: {{patient_birthdate}}

By signing below, I acknowledge that I have received a copy of the Notice of Privacy Practices.

Signature of Individual:

Signature of Witness/ Provider:

Date: {{current_date}}

BELOW THIS IS FOR OFFICE USE ONLY:
We attempted to obtain written acknowledgement of the opportunity for receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

Other:

Notice of Privacy Practices is prominently displayed within the facility.

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., Co., Primary Medical of IN, P.C.
2025.07.09

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Acknowledgement of Receipt of Notice of Privacy Practices (Brick-and-Mortar)

Unique Document ID: 49c3a0277128b14e2abb6eaafacc07c61cbe1282

Build. Track. Sign Contracts.

Timestamp

Audit

2026-08-25 16:13:21 UTC

Document Acknowledgement of Receipt of Notice of Privacy Practices (Brick-and-Mortar)
Uploaded by EnnuLife - docs-admin-ennulife@ennulife.com
IP: 0.0.0.0