Free standard privacy practices acknowledgment — professional wording your business can adapt in minutes. Available in English, Español and 中文. Swap the [bracketed] parts, or let KwickPhone fill in your business name automatically.
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Acknowledgment of Notice of Privacy Practices
I acknowledge that [Business Name] offered me its Notice of Privacy Practices, which describes how my health information may be used and disclosed and how I can access it. I may request restrictions on certain uses, and I may list persons the office may discuss my care with: [authorized contacts]. Preferred contact method for appointment and health matters: [phone / text / email].
Acuse de Recibo del Aviso de Prácticas de Privacidad
Reconozco que [Nombre del Negocio] me ofreció su Aviso de Prácticas de Privacidad, que describe cómo puede usarse y divulgarse mi información de salud y cómo puedo acceder a ella. Puedo solicitar restricciones sobre ciertos usos, y puedo indicar personas con quienes el consultorio puede hablar de mi atención: [contactos autorizados]. Método de contacto preferido para citas y asuntos de salud: [teléfono / texto / correo].
⚖️ These templates are general starting points, not legal advice. Rules differ by state and by business — have your attorney review your final wording before you use it.
State-by-state differences
TX — Texas: informed-consent disclosures follow the Texas Medical Disclosure Panel lists; document consent for procedures on List A in writing.
CA — California: patients may request records within 5 working days (inspection); CMIA privacy rules apply on top of federal privacy requirements.
FL — Florida: dental records must be kept at least 4 years (Board rule); patient-abandonment rules require 30 days' coverage after ending care.
NY — New York: patient records must be retained 6 years (adults) or until a minor turns 22; surprise-bill disclosures apply to out-of-network care.
IL — Illinois: dental records generally retained 10 years; patients get copies within 30 days of a written request (fees capped by statute).
NJ — New Jersey: patient records kept at least 7 years from the last entry; provide copies within 30 days of request.
GA — Georgia: retain records 10 years from the last entry (minors longer); Board of Dentistry rules govern transfers when a practice closes.
CO — Colorado: dental board rules require records for 7 years after the last treatment (or age 25 for minors, whichever is later).
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