Patient Rights Acknowledgment
Please review and acknowledge your patient rights below.
PATIENT RIGHTS & ACKNOWLEDGMENT
PATIENT RIGHTS ACKNOWLEDGMENT
I acknowledge that I have received and understand my rights, including:
✔ Right to respectful care
✔ Right to refuse services
✔ Right to file complaints
✔ Right to privacy (HIPAA)
Patient Name
*
First Name
Last Name
Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Acknowledge
Acknowledge
Should be Empty: