Hipaa Consent Forms - Wellstar Health System (Page 2 of 3) in pdf

Hipaa Consent Forms - Wellstar Health System Page 2

Acknowledgment of Receipt of “Notice of Privacy Practices”

for Protected Health Information

I acknowledge that I have received a copy of WellStar Health System’s “Notice of Privacy Practices” for

protected health information on the date set forth below.

Date of Receipt

Patient Information

(please print clearly)

_______________________________________________

________________________

Last Name

First Name

Middle Initial

Date of Birth

(Month/Day/Year)

___________________________________________________________

_______________________________________

Print Patient Name or Legal Guardian/Personal Representative

Relationship to Patient

Signature of Patient or Legal Guardian/Personal Representative

Release and Assignment:

The information I have given is correct to the best of my knowledge. I understand that it will be held in the

strictest confidence, and it is my responsibility to inform the WellStar Medical Group of any changes in my

address, phone number or insurance. I understand that I am financially responsible for any amounts not

covered by my insurance. _______________

For use by WellStar Personnel Only

(complete this section if patient acknowledgement is not received)

An Acknowledgment of Receipt of Notice of Privacy Practices was not received because:



Patient refused to sign Acknowledgment



Unable to gain signed Acknowledgment due to communication/language or other barrier



Patient was unable to sign Acknowledgment due to emergency treatment situation



Other: Please indicate reason _______________________________________________________

Signature of WellStar Representative: _____________________________________ Date: _____________

Hipaa Consent Forms - Wellstar Health System Page 2