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  • **ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES** Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or document our good faith effort to obtain that acknowledgement. **You May Refuse to Sign This Acknowledgement** I, **JOHN SMITH**, have received a copy of this office's Notice of Privacy Practices. Please Print Name: John Smith Signature: [Signature] Date: 1/7/2017 --- **AUTHORIZATION TO RELEASE INFORMATION** Purpose: This form is used to obtain authorization to release information regarding yourself covered under the Privacy Act to people other than yourself. I, **JOHN SMITH**, authorize the following person(s) to have access to information covered under the Privacy Practices regarding myself. Please Print Name: Jane Smith Relationship: Wife --- **Ambir** **SAFETY** **JOHN SMITH** 123456789012345 67/17

    Ambir Technology Inc - ImageScan Pro 820ix for use with athenahealth - 48-bit 16-bit Grayscale - 20 ppm (Mono) - 20 ppm - Color

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    Not yet reviewed
  • **Acknowledgement of Receipt of Notice of Privacy Practices** Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or document our good faith effort to obtain that acknowledgement. **You May Refuse to Sign This Acknowledgement** I, **John Smith**, have received a copy of this office's Notice of Privacy Practices. **John Smith** Signature Date: 1/7/2017 --- **Authorization to Release Information** Purpose: This form is used to obtain authorization to release information regarding yourself covered under the Privacy Act to people other than yourself. I, **John Smith**, authorize the following person(s) to have access to information covered under the Privacy Act regarding myself. **Jane Smith** Wife Relationship --- **Ambir** **Safety** **John Smith** 1234 5678 9012 3456 07/17

    Ambir Technology Inc - ImageScan Pro 830ix for use with athenahealth - 48-bit 16-bit Grayscale - 30 ppm (Mono) - 25 ppm - Color

    Not yet reviewed

    Not yet reviewed
  • POCE - Ambir

    Ambir Technology Inc - AMBIR ImageScan Pro 340 Sheetfed Scanner - 600 dpi Optical - 48-bit 16-bit Grayscale - 40 ppm (Mono) - 40 ppm - Color

    Not yet reviewed

    Not yet reviewed
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