Notice of Privacy Practices | Charlotte Braces (Z&G) Step 1 of 3 33% Notice of Privacy PracticesAcknowledgement of Receipt of Notice of Privacy Practices.Patients’ Name * Required First Middle Initial Last Patient InformationAddress * Required Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Birthdate * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Acknowledgement Of Receipt Of Notice Of Privacy PracticesBy signing my name to this online form, I certify that I have read the information and that any questions concerning these policies have been discussed. My signature also certifies my understanding of and agreement with the policies or guidelines. A photocopy of this document is as valid as the original. You may receive a copy of this document upon request.Responsible Name * Required First Middle Initial Last Relationship to Patient * Required Signature * Required
