rblaseraesthetics.com - Acknowledgement of Receipt and Privacy Practices

Acknowledgement of Receipt and Privacy Practices
I have received a copy of the “Notice Of Privacy Practices”. The Notice describes how my health information may be used or disclosed. I understand that I should read it carefully. I am aware that the Notice may be changed at any time. I may obtain a revised copy of the Notice by calling (760) 200-2992 or by requesting the Notice in person at: The Medical Center At Indian Wells, 45280 Club Dr, Indian Wells Ca, 92210
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As the representative of the above individual, I acknowledgement receipt of the Notice on his/her behalf.
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This acknowledges that the physician, or his staff members, have provided me with information concerning Advance Directives.
1. I am age 18 or older.

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2. I realize that I have the option of putting together Advanced Directives for my healthcare. My physician has provided me written information concerning the Advance Directives. I understand that it is my responsibility to provide my doctor(s) with any documents that are required to carry out my Advanced Directives.

3. I am aware that Advanced Directives may be any one of the following:
1. A durable power of Attorney For Health Care.
2. The declaration in the A Natural Death Act-Ex. A Living Will
3. I may down my wishes on a piece of paper so that my family may use the document, ¡n deciding my medical treatment, in the event I am unable to do so.
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Acknowledgement of Receipt and Privacy Practices

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