Port Charlotte Dentist    Privacy Acknowledgement    Charlotte County Dentistry

Acknowledgment of Receipt of Notice of Privacy Practices.  You May Refuse To Sign This Acknowledgment.

This form acknowledges you have received our Notice of Privacy Practices. You can print this form, fill it out and fax it to 941-743-2988, mail it to our office, or bring it with you for your scheduled appointment. By submitting this form to Port Charlotte, FL Periodontist Carol W. Stevens, D.D.S., M.B.A. you are Acknowledging you have received a copy of this office's Notice of Privacy Practices.

Download the PDF version here: Privacy-Policy-Acknowledgement.pdf. This form requires a PDF Reader. You can download Acrobat Reader for free to view and print our forms.

We value your privacy and want you to be informed of how we may use and disclose your protected health information. For specifics about our policies, read our Privacy Practices.

I acknowledge I have received a copy of the Notice of Privacy Practices from Carol W. Stevens, D.D.S., M.B.A. A copy of this signed and dated Acknowledgment shall be as effective as the original.

Port Charlotte Dentist  Acknowledgement of Receipt

Your full name: _______________________________________________ * Required

Patients name: _______________________________________________ (if different from above)

Authorizing signature: ____________________________________  Date: __________________ *Required

By submitting this form, I am in full agreement with the terms stated above.

If you have any questions about this form or the Notice of Privacy Practices, please contact our office.