Notice of Privacy Practice (NPP) Policy Pamphlet

Purpose : To provide that patients and other interested persons have a defined opportunity to receive adequate notice of 1) the uses and disclosures of protected health information (“PHI”) that may be made by the provider; 2) patient rights concerning PHI; and 3) the provider’s legal duties pertaining to PHI.

The information in this document applies to all staff, students, volunteers, and any other contractors, business associates or agents granted access to Protected Health Information (PHI).


Protected Health Information (PHI) : Individually identifiable health information transmitted or maintained in any form or medium, including oral, written, and electronic. Individually identifiable health information relates to an individual’s health status or condition, furnishing health services to an individual or paying or administering health care benefits to an individual. Information is considered PHI where there is a reasonable basis to believe the information can be used to identify an individual.

Treatment, Payment, and Health Care Operations (TPO): Three core functions of providing health care to patients.

  • Treatment involves the administering, coordinating and management of health care services by WKHS for its patients.
  • Payment includes any activities undertaken either by WKHS or a third party to obtain premiums, determine or fulfill its responsibility for coverage and the provision of benefits or to obtain provide reimbursement for the provision of health care.
  • Health Care Operations are activities related to WKHS’ functions as a health care provider, including general administrative and business functions necessary for WKHS to remain a viable health care provider.
    • For a more detailed definition of TPO, Please see General Uses and Disclosures Policy.

Policy : An individual has a right to adequate notice of the uses and disclosures of PHI that may be made by WKHS, and of the individual’s rights and WKHS’s responsibilities with respect to PHI. WKHS is required to provide a notice of privacy practices document to all patients, as well as other individuals requesting a copy. Those persons who register or admit patients will be responsible for distributing a copy of the notice to all patients.

  1. Reasonable effort shall be made to provide patients or their legally authorized representative the current Notice of Privacy Practices (NPP) on the date of the first service delivery on or after the April 14, 2003, compliance date. An exception exists where the first service delivery involves emergency medical treatment; in such cases, the NPP shall be provided as soon as it is reasonably practicable to do so.
  2. Except in emergencies, reasonable effort shall be made to obtain a signed acknowledgement of receipt of the current NPP from the patient or the legally authorized representative.
  3. Documentation of reasonable attempts to provide the current NPP by the signed acknowledgement of receipt shall be maintained in the medical record. Refusals to sign the acknowledgement, or refusals to accept the NPP, shall also be documented.
  4. A current NPP will be posted in a prominent location where it is reasonable to expect that patients will see and have an opportunity to read the document. At any time, a patient or the patient’s legally authorized representative may request and receive a copy of the current NPP.
  5. The NPP shall describe actual privacy practices and examples of all uses and disclosures of PHI. Any change to actual privacy practices shall be reflected in the NPP. Subsequent to any revision, a copy of the “old” NPP shall be retained for 6 years from the date it was last effective.
  6. Any person, not only a patient, having questions about the NPP, or privacy or confidentiality practices, shall be directed to the Privacy Officer for further information if necessary.
  7. Any member of the general public (who is not a patient or a patient’s legally authorized representative) requesting the NPP shall be provided the current NPP as promptly as circumstances permit. The documentation requirements do not apply.

Primary Responsible Party:

Privacy Officer and Health Care Access or WKHS Network Physician Office Staff

Other Responsible Party:

All staff should have general knowledge and be able to direct questions/concerns appropriately)

Procedure :

  1. Patients or their legally authorized representative must be provided the current Notice of Privacy Practices (NPP) no later than the date of the first service delivery, falling on or after the April 14, 2003, Privacy Rule compliance date.

    a) Ask the individual to sign the written acknowledgement statement . The signed document shall be filed and maintained in the patient record. A copy of the notice must be distributed to the patient without any express or implied request to return it. It is permissible to have a “recycle” basket with a sign stating, “You have a right to keep the notice of privacy practices. If you do not wish to keep it, please place it in this basket.”

    b) If the individual refuses the offered NPP or declines to sign the acknowledgement form:

    i) Document the refusal on the acknowledgement of receipt form, and

    ii) File it in the medical record, for example: “Mr. Smith declined to accept NPP” or “Mr. Smith accepted NPP, but refused to sign the acknowledgement form when requested.”

    iii) Sign and date the notation.

  2. There is no requirement to provide the current NPP, or attempt to do so, where the first patient encounter involves emergency medical treatment, making the provision of notice and related documentation requirements impractical and/or inappropriate.

    a) The documentation in the medical record should corroborate that the patient required and received emergency medical treatment. In such cases, the current NPP shall be provided as soon as it is reasonably practical to do so.

    b) This may be when the patient has stabilized, at the next scheduled appointment, via mail if it appears the patient may not return for another appointment, or by any other means reasonable and appropriate under the specific circumstances.

  3. Copies of the current NPP shall be maintained and available to give to any patient, legally authorized representative, or other person, so requesting. A charge for a copy of the NPP is not permissible under HIPAA.

  4. The NPP shall be revised whenever there is a material change to the uses or disclosures, the individual’s rights, WKHS’ legal duties, or other privacy practices stated in the notice. Except when required by law, a material change to any term of the notice may not be implemented prior to the effective date of the notice in which such material change is reflected.

  5. Patients receiving the NPP who have questions or desire further information should be directed to the practice/health care facility Privacy Officer, as necessary. Every effort should be made to help interested patients understand the information contained in the NPP.

Policies and Procedures Specific to Electronic Notices of Privacy Practices and/or Electronic Service Delivery:

  1. The current NPP will be prominently posted on the Web site and made readily available electronically through our Web site.


    a) The individual who is the recipient of electronic notice retains the right to obtain a paper copy of the notice from WKHS upon request.

  2. The current NPP may be provided by e-mail if the patient or individual agrees. If WKHS knows that the e-mail transmission has failed, a paper copy of the notice must be provided to the individual.
  3. If the first service is delivered electronically, the patient shall be provided the current NPP automatically and contemporaneously in response to the first request for service.
  4. The required “written acknowledgement” should be captured electronically, by whatever means technologically feasible.

a) If it is not feasible (patient does not have e-mail or facsimile machine) to deliver the NPP as required by the rule, WKHS will inform the patient that the NPP will be mailed along with the acknowledgement form (for the patient to complete and return).

i) Documentation will be maintained of all NPPs and Acknowledgement Forms mailed and received.

References :

RCW: 70.02.120
45 CFR Subtitle A, Subchapter C. Section 164.520