Patient Acknowledgment of Receipt of
Notice of Privacy Practices

,hereby acknowledge that I have reviewed and received a copy of this office's Notice of Privacy Practices explaining:
  • How this will use and disclose my protected information.
  • My privacy rights with regard to my protected information.
  • This offices obligations concerning the use and disclosure of my protected information.
I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices upon request.
I also understand that if I have any questions or complaints, I may contact:

Thomas G. Acierno, D.D.S.
2615 Clairemont Drive
San Diego, CA 92117
You may also contact the Secretary of the U.S. Department of and Human Services with any concerns regarding our privacy and security policies and procedures. Please contact our for information on how to contact the U.S. Department of and Human Services.

Patient or Personal Representative