Acknowledgement of Receipt of Notice of Privacy Practices I, , acknowledge and agree that I have received a copy of Integrative Pain Center of Alaska, LLC’s Notice of Privacy Practices. PATIENT’S SIGNATURE: DATE: PATIENT LEGAL REPRESENTATIVE ( if applicable): DATE: PRINT NAME OF LEGAL REPRESENTATIVE: RELATIONSHIP TO PATIENT: FOR CLINIC USE ONLY: Integrative Pain Center of Alaska, LLC made the following good faith efforts to obtain the above – referenced individual’s written acknowledgement of receipt of North of Privacy Practices: (Identify the efforts that were made to obtain the individual’s written acknowledgement, including the reasons (if known) why the writte acknowledgement was not obtained.)