Consent for Release of Protected Health Information

Please correct the errors described below.

I consent to disclosure of the following protected health information about my child to the following family
member(s) or person(s) involved in my child’s care or payment for my child’s care:

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My consent will remain in effect as long as my child is a patient of Blue Ridge Pediatrics, LLP unless and until I notify Blue Ridge Pediatrics, LLP in writing of any changes.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Although allowed under HIPAA, North Carolina law does not permit release of PHI outside of the Hospital unless required by law, pursuant to a court order or patient authorization, or for treatment, payment, or health care operations purposes as defined and limited by HIPAA. There is no exception for family members except for residents of a nursing home. The North Carolina physician‐patient privilege statute, N.C.G.S. § 8‐53, and HIPAA allow verbal authorization or consent for release, respectively, of information to family members. However, the better practice is to document the patient’s consent in order to have clear evidence of the patient’s intent. The package does not include a consent or authorization to release PHI to other providers or to insurance companies or others since most providers already have such forms. The contents of this form can be combined with such existing consent forms.

Your information will be encrypted.