Acknowledgement of Offer of Notice of Privacy Practices
Account Information



Acknowledgement of Offer of Notice of Privacy Practices

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.

If not signed by the patient, please indicate relationship: