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[email protected]
Account #:
Today's Date:
Privacy Officer: Rachelle Nicklas, MHA – (951)698- 1901 ext. 206
I hereby acknowledge that I have been offered a copy of this medical practice’s Notice of Privacy Practices. I further acknowledge that a copy of the current notice is available in the reception area and that additional copies are available to me upon my request.
Name/Signature:
Date:
Telephone:
If not signed by the patient, please indicate relationship:
Parent or guardian of minor patient
Guardian or conservator of an incompetent patient
Beneficiary or personal representative of deceased patient