THE UNDERSIGNED PATIENT OR GUARDIAN WAS INFORMED REGARDING
THE THE FOLLOWING REQUIRED DOCUMENTS
- Patient / Guardian recieved a copy of the "Patient's Rights" for Surgicare of Central Jersey?
Yes___ No___
- Patient / Guardian recieved a copy of the "Notice of Privacy Practices" for Surgicare of Central Jersey?
Yes___ No___
- Does the patient have an Advanced Directive (Living Will, Durable Power of Attorney, Proxy)?
Yes___ No___
NOT APPLICABLE TO THIS ADMISSION ( )
- If answer to number 3 is yes, did patient provide a copy on admission?
Yes___ No___
- Written information regarding Advance Directive was provided to patient?
Yes___ No___
PATIENT/GUARDIAN SIGNATURE _____________________________________________
DATE ______________________________________
