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Patient Bill of Rights Receipt - Generic Template Mobile App

This Patient Bill of Rights Receipt mobile app can be used to gain informed consent after discussing HIPAA privacy rules, collection of patient records, and the rights and responsibilities of the patient. You can easily capture the signature or the patient or legal guardian.

All signed medical records and medical information are securely stored in the GoCanvas Cloud. They can be printed or emailed as a PDF if you need to send them to another health care professional, health insurance company, or family member. This app can be downloaded to an iPhone, iPad, or Android device.

  • Lendlease
  • The Cooperative
  • PG&E
  • Toys R Us
  • Red Bull
  • Mirvac

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Take a peek inside the Patient Bill of Rights Receipt - Generic Template Mobile App

Included Features

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Included Fields

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

  • Ico statictext

    Receipt of Privacy Notice & Patient Bill of Rights

  • Ico statictext

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

  • Ico textbox

    Facility Name:

  • Ico textbox

    Patient Name:

  • Ico camera

    Signature of Patient and/or Legal Guardian:

  • Ico textbox

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

  • Ico date

    Date Signed:

  • ...and More!

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