Acknowledgment of Receipt of Notice of Privacy Practices for Protected Health Information I acknowledge that I have received a copy of WellStar Health Systems Notice of Privacy Practices for protected health information on the date set - - 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date of Receipt' in the designated field. Ensure the date is accurate as it reflects when you received the notice.
3. Fill in your personal information clearly. Start with your 'Last Name', followed by 'First Name' and 'Middle Initial'.
4. In the next section, print your name or that of your legal guardian/personal representative clearly.
5. Indicate your 'Relationship to Patient' if applicable, and then sign in the provided space to acknowledge receipt.
6. Review the 'Release and Assignment' section, ensuring all information is correct before signing.
7. If you are a WellStar representative completing this form, fill out the necessary details in the personnel section as required.

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