Patient Bill of Rights Receipt - Generic Template Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  Receipt of Privacy Notice & Patient Bill of Rights

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  I certify that I have been given a copy of this facilities Privacy Notice and Patient Bill of Rig...

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  Facility Name:

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  Patient Name:

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  Signature of Patient and/or Legal Guardian:

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  If not patient signing form, please state relationship to patient:

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  Date Signed:

• ...and More!