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:
Parent or guardian of minor patient
Guardian or conservator of an incompetent patient
Beneficiary or personal representative of deceased patient