420 N Evergreen Rd # 400, Spokane Valley, WA 99216

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I have read and been offered a hard copy or an electronic copy of theHIPAA Notice of Privacy Practicesfor Hymas Family Dental. I understand that I am entitled to receive a hard copy of the Notice if I ask for it, even if I have already agreed to receive only an electronic copy.
Relationship to patient: Self Parent Guardian Legal Representative
If applicable:
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