Privacy Notice

Notice of Privacy Practices


Why you are receiving a Notice from your doctors and health plan

Your health care provider and health plan must give you a notice that tells you how they may use and share your health information and how you can exercise your health privacy rights. In most cases, you should get this notice on your first visit to a provider or in the mail from your health insurer, and you can ask for a copy at any time.  The provider or health plan cannot use or disclose information in a way that is not consistent with their notice.

Why you are asked to “sign” a form

The law requires your doctor, hospital, or other health care provider you see in person to  ask you to state in writing that you received the notice.  Often, that means the doctor will ask you to sign a form stating that you received the notice that day.

  • The law does not require you to sign the “acknowledgement of receipt of the notice.”
  • Signing does not mean that you have agreed to any special uses or disclosures of your health records.
  • Refusing to sign the acknowledgement does not prevent the entity from using or disclosing health information as the Rule permits it to do.
  • If you refuse to sign the acknowledgement, the provider must keep a record that they failed to obtain your acknowledgement.


PHNB NPP 01.01.12