Complete Privacy Notice     Acknowledgment

Acknowledgement of Receipt of Notice

I hereby acknowledge that I received a copy of this agency's Notice of Privacy Practices.

I would/would not like to receive a copy of any amended Notice of Privacy Practices by e-mail at:

_____________________________.

Signed: ______________________________ Date:________________

Print Name: __________________________ Telephone: __________________

If not signed by the consumer, please indicate relationship:

     ____parent or guardian of minor

     ____legal guardian

     ____beneficiary or personal representative of deceased consumer

Name of Consumer: _____________________________________________

For Office Use Only:

Signed form received by: ________________________________________

Acknowledgment refused:

     Efforts to obtain:    ________________________________________________________________

     Reasons for refusal:   ________________________________________________________________

(c) 2001 by PrivaPlan Associates, Inc. Patent Pending. All rights Reserved.