![**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
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**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
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