Wellstar Medical Group Acknowledgment of Receipt Notice of Privacy Practices 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date of Receipt' in the designated field. This is important for record-keeping purposes.
3. Next, fill in the 'Patient Date of Birth' to ensure accurate identification.
4. In the 'Print Patient Name' section, clearly type the full name of the patient as it appears on their identification.
5. If applicable, enter the 'Print Name of Authorized Personal Representative'. This is necessary if someone else is signing on behalf of the patient.
6. The patient or authorized representative should then sign in the 'Patient Signature' field. If an authorized representative is signing, they must also sign in their respective field.
7. Indicate the relationship to the patient if an authorized representative is signing by filling out that section.
8. For Wellstar personnel, complete any necessary fields regarding acknowledgment receipt if not obtained, including reasons and signatures as required.

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