{"content":[{"text":"E. E. OJA, D.D.S. \n ACKNOWLEDGEMENT OF RECEIPT OF \n NOTICE OF PRIVACY PRACTICES","bbox":{"left":0.252446,"top":0.075243,"width":0.4957789999999999,"height":0.08945199999999998}},{"text":"**You May Refuse to Sign This Acknowledgement**","bbox":{"left":0.292245,"top":0.182418,"width":0.41611600000000004,"height":0.016460000000000002}},{"text":"I, ____________________________________, have received a copy of this office’s Notice of \n Privacy Practices","bbox":{"left":0.070981,"top":0.235447,"width":0.8082030000000001,"height":0.036469999999999975}},{"text":"_______________________________________________ \n (Print Name)","bbox":{"left":0.188628,"top":0.308781,"width":0.503085,"height":0.03646999999999995}},{"text":"_______________________________________________ \n (Signature)","bbox":{"left":0.188628,"top":0.381811,"width":0.503085,"height":0.03647}},{"text":"_______________________________________________ \n (Date)","bbox":{"left":0.188628,"top":0.454841,"width":0.503085,"height":0.036773}},{"text":"For Office Use Only","bbox":{"left":0.423922,"top":0.531508,"width":0.1673929999999999,"height":0.01828799999999997}},{"text":"We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but \n acknowledgement could not be obtained because:","bbox":{"left":0.070981,"top":0.570902,"width":0.853813,"height":0.036772999999999945}},{"text":"( )","bbox":{"left":0.188628,"top":0.644235,"width":0.021145000000000025,"height":0.01828799999999997}},{"text":"Individual refused to sign","bbox":{"left":0.247451,"top":0.644235,"width":0.21934500000000004,"height":0.01828799999999997}},{"text":"( )","bbox":{"left":0.188628,"top":0.680599,"width":0.021145000000000025,"height":0.01828799999999997}},{"text":"Communications barriers prohibited obtaining the acknowledgement","bbox":{"left":0.247451,"top":0.680599,"width":0.589931,"height":0.01828799999999997}},{"text":"( )","bbox":{"left":0.188628,"top":0.717265,"width":0.021145000000000025,"height":0.01828799999999997}},{"text":"An emergency situation prevented us from obtaining acknowledgement","bbox":{"left":0.247451,"top":0.717265,"width":0.617676,"height":0.01828799999999997}},{"text":"( )","bbox":{"left":0.188628,"top":0.753932,"width":0.021145000000000025,"height":0.01828799999999997}},{"text":"Other (Please Specify)","bbox":{"left":0.247451,"top":0.753932,"width":0.19250599999999998,"height":0.01828799999999997}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}