Consent for Release of Protected Health Information

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:

**List names other than parents. If no one else should receive this information, please write “No one.”**

Add new names

Check all that may apply:

All of my child’s medical information

Information necessary to schedule appointments for my child

Lab or test results

Information necessary to provide, call in or pick up prescriptions for my child

Information necessary to help my child’s family member(s) take care of my child

Information necessary to allow my child’s family member(s) to pick up or arrange for medical equipment to be provided for my child

Information necessary to bill for or submit claims for care provided to my child to government or private insurance payors

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.

Patient’s Name:

Patient's Date of Birth:

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.

Signature of Patient or Representative

Date

Print Name:

Relationship to Patient:

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.