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· ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 6054415041 S Van Dyke Rd Ste 105

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Page 1: · ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 6054415041 S Van Dyke Rd Ste 105

Page 2: · ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 6054415041 S Van Dyke Rd Ste 105

Page 3: · ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 6054415041 S Van Dyke Rd Ste 105

Page 4: · ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 6054415041 S Van Dyke Rd Ste 105

Page 5: · ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 6054415041 S Van Dyke Rd Ste 105

Page 6: · ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 6054415041 S Van Dyke Rd Ste 105

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