Resident Rights Acknowledgement

Form 11 of 12

Note: Fields marked with an * indicates required field

Rights of Residents in Michigan Nursing Facilities

The undersigned hereby acknowledges receipt of the "Rights of Residents in Michigan Nursing Facilities" that he/she has been fully informed of those rights, and was given the opportunity to ask questions relative to their nature and scope.

If signing on the Residents behalf, please provide the Resident's name in the Resident section.

By submitting this Consent Form, please be aware that an electronic signature is as legally binding as a handwritten signature.

This form will be updated annually or upon request by the resident/legal representative.