Page 1 of 3
Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Notice of Privacy Practices
Policy Number: 6.29
Effective Date: May 1, 2015
Chapter: Medical Records
To provide patients with information about UWHC's practices for maintaining the privacy and security of
protected health information.
UWHC must make a good faith effort to provide patients or their legally authorized representatives with a
copy of its "Notice of Privacy Practices," ("notice") and have the patient or the patient's legally authorized
representative sign the "Acknowledgment of Receipt of Privacy Practices" ("acknowledgement") form.
The notice need only be given and the acknowledgment need only be obtained once by UWHC.
A. Protected Health Information-individually identifiable health information that is transmitted, or
maintained in any form, including oral, written, or electronic. Protected health information
includes demographic, health and financial information.
B. Legally Authorized Representative-a person with authority under state law or hospital policy to
act on behalf of the patient. For example, a parent, guardian, spouse, or person holding an
activated and valid power of attorney.
C. Access Point-any clinical area in which the patient would present for services. Access points
include, but are not limited to inpatient admissions, clinics and Emergency Department reception
and registration, pharmacy, and home health.
A family member or other person accompanying the patient, or participating in their care may
receive the notice on behalf of the patient, but if the patient has the capacity, only the patient may
sign the acknowledgement. If the patient is incapacitated, a minor, incompetent or deceased, the
notice may be provided to and the acknowledgement obtained from the patient's legally
authorized representative. If a patient is a minor, UWHC will provide the notice to and obtain the
acknowledgement from the patient's legally authorized representative (e.g. parent, guardian).
Page 2 of 3
When the patient turns eighteen, unless incompetent or incapacitated, UWHC will provide the
notice to and obtain the acknowledgement directly from the patient.
B. Patients Presenting At UWHC
1. Patients or their legally authorized representatives, who present at one of UWHC's access
points for services, must be given a copy of UWHC's Notice of Privacy Practice and must
be asked to sign the "Acknowledgment of Receipt of Privacy Practices" form.
2. Staff in all access points are responsible for providing the notice and obtaining the
acknowledgement if it has not yet been done.
3. Admissions, reception, and registration staff are responsible for entering documentation
of providing the notice.
4. Staff in areas other than admissions/registration (e.g. social work, pharmacy, reception)
must forward the signed acknowledgement to UWHC's Admission Department or the
nearest centralized registration site (e.g. West, East, University Station, Research Park).
5. Admissions and registration staff is responsible for recording the acknowledgement date.
6. Patients who bypass admissions or registration/reception because of incapacity or
emergency circumstances must be given the notice as soon as possible after the patient
regains capacity (if applicable) or as soon as possible after the emergency circumstances
a. Inpatient-admissions staff will follow-up with the patient during the first 48
hours after admission. If admissions staff is still unable to provide the notice and
obtain the acknowledgement, social work staff will attempt to do so up until the
patient is discharged. Admissions and social work staff must document failed
attempts to both provide the notice and to obtain the acknowledgement. If staff
has been unable to provide the notice and obtain acknowledgement despite
attempts to do so, UWHC staff must provide the notice and obtain the
acknowledgement from the patient or the patient's legally authored representative
on a subsequent visit.
b. Clinics and other Access Points-it should be the rare exception in the clinic
setting that the patient or the patient's legally authorized representative is not
given the notice and their acknowledgment obtained (e.g. extreme
illness/discomfort by the patient). In these rare circumstances, if a patient or their
legally authorized representative is not provided a notice or if staff are unable to
obtain the acknowledgement, clinic staff should mail the materials to the
individual and record, the date the notice and acknowledgment was mailed.
Returned acknowledgments will be directed to the UWHC Admissions
Department or the registration site where the patient received care. Admissions
and registration staff are responsible for recording any returned
C. Patient Refuses to Sign Acknowledgement. If patient refuses to accept the notice or refuses to
sign the acknowledgement, staff will document the refusal. Patients who refuse will not be asked
to accept the notice or sign the acknowledgment at subsequent visits.
D. Posting of Notice. UWHC must post its Notice of Privacy Practice on its webpage, at all access
points, and make it available to all individuals who request it.
E. Notice to Non-English Speaking/Reading Individuals. Copies of the notice and acknowledgement
will be available in English and such other languages as determined by UWHC leadership.
Patients who do not speak or read English or those other languages will be given the notice and
the acknowledgment form in English and offered Interpreter services.
Page 3 of 3
Notice of Privacy Practices
Acknowledgement of Notice of Privacy Practices
Senior Management Sponsor: SVP, General Counsel
Author: Compliance and Privacy Officer
Approval Committee: Administrative Policy and Procedure Committee
President & CEO
Previous revision: May 2012
Next revision: May 2018