{Timothy M. Hale D.D.S Katy Periodontics Management, Inc.} ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I, ______________________________________, have received a copy of this office's Notice of Privacy Practices. ____________________________________ {Signature} ____________________________________ {Date} For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: [] Individual refused to sign ¨ [] Communications barriers prohibited obtaining the acknowledgement [] An emergency situation prevented us from obtaining acknowledgement [] Other (Please Specify)   ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________