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 - - 2025

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A covered health care provider with a direct treatment relationship with individuals is required to make a good faith effort to obtain an individuals acknowledgement of receipt of the notice only at the time the provider first gives the notice to the individual -- that is, at first service delivery.
Individuals have the right to know how their protected health information may be used and disclosed, and what their privacy rights are. The Notice of Privacy Practices (NPP) provides individuals with this information.
HIPAA also requires you to obtain patients written acknowledgement that notice has been received and file the acknowledgement in the patient record. A patients refusal to sign the acknowledgement should be documented and filed in the patient record. A sample Notice of Privacy Practices can be. downloaded here.
The Notice of Privacy Practices must inform patients of how their PHI will be used and disclosed (with examples), the covered entitys responsibilities for safeguarding the privacy of PHI, and their rights to restrict certain uses and disclosures, choose how they are communicated with, request a copy of their PHI,
Your health care provider and health plan must give you a notice that tells you how they may use and share your health information. It must also include your health privacy rights. In most cases, you should receive the notice on your first visit to a provider or in the mail from your health plan.
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