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