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Alex M. Pentino, DDS 107 Plaza Drive Suite F St. Clairsville, OH 43950 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES * You May Refuse to Sign This Acknowedgement* have

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Page 1: Alex M. Pentino, DDS 107 Plaza Drive Suite F St. Clairsville, OH 43950 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES * You May Refuse to Sign This Acknowedgement* have

Page 2: Alex M. Pentino, DDS 107 Plaza Drive Suite F St. Clairsville, OH 43950 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES * You May Refuse to Sign This Acknowedgement* have

Page 3: Alex M. Pentino, DDS 107 Plaza Drive Suite F St. Clairsville, OH 43950 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES * You May Refuse to Sign This Acknowedgement* have

Page 4: Alex M. Pentino, DDS 107 Plaza Drive Suite F St. Clairsville, OH 43950 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES * You May Refuse to Sign This Acknowedgement* have

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