Rancho Physical Therapy -- Acknowledgement of Receipt of Notice of Privacy Practices

PF-2000 Acknowledgement of Receipt of Notice of Privacy Practices

Rancho Physical Therapy reserves the right to modify the privacy practices outlined in the notice.

Signature
I have received a copy of the Notice of Privacy Practices for Rancho Physical Therapy.

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Name of Patient (Print or Type)

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Signature of Patient

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Date

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Signature of Patient Representative
(Required if the patient is a minor or an adult who is unable to sign this form)

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Relationship of Patient Representative to Patient