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![Page 1: 360Core€¦ · I hereby authorize Manouchehr Nikpour, P.C. to receive and/or release any medical or other information that may be necessary for the medical care or processing of](https://reader033.vdocuments.us/reader033/viewer/2022050307/5f6ff4badae0c1523f48fec8/html5/thumbnails/1.jpg)
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[NAME OF PRACTICE]
ACKNOWLEDGEMENT OF RECEIPT'OF :NOTICE OF PRIVACY PRACTICES
The undersigned Patient or legally authorized representative ("Agent") of the Patient acknowledges that he or she personally received a copy of the [NAME OF PRACTICE]'s Notice of Privacy Policies on the date indicated below.
Signature: Date:
Patient:
Information about Agent (attach appropriate documentation):
Agent:
Title:
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