PATIENT ACKNOWLEDGEMENT
I, _____________________________ , hereby declare that all the information I provided is true and current to the best of my knowledge. I recognize Rejuvenate Health Centers ability to provide the best care possible and give them permission to advise and treat me accordingly as well as obtain payment for the treatment in order to carry out its health care operations.
I also acknowledge that Rejuvenate Health will keep all of my information private according to the required Protected Health Information (PHI) policy. The Rejuvenate Health Privacy Notice contains all guidelines to protecting my information and I am aware that I can request to read it at any time. It is provided at the front desk for my convenience. I acknowledge that Rejuvenate Health reserves the right to change its privacy practices that are described in the. Privacy Notice, in accordance with applicable law.
I have read and understand the foregoing notice and all of my questions have been answered to my full satisfaction in a way that I understand it.