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
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Month
-
Day
Year
Date
Acknowledge
Should be Empty: