Patient Acknowledgment and Consent

Please correct the errors described below.



If you have any questions about this notice, please contact the Blue Ridge Pediatrics, LLP Privacy Officer Tina M. Guinazu at (919) 782-0021.


This notice describes the practices of:

  • Blue Ridge Pediatrics, LLP
  • Any health care professional authorized to enter information into your medical record maintained by Blue Ridge Pediatrics, LLP
  • Any persons or companies with whom Blue Ridge Pediatrics, LLP contracts for services to help operate our practice and who have access to your medical information.
  • All these persons, entities, sites, and locations follow the terms of this notice. In addition, these persons, entities, sites, and locations may share medical information with each other for treatment, payment, or health care operations purposes and other purposes described in this notice.


We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive from Blue Ridge Pediatrics, LLP.

We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care and billing for that care that are generated or maintained by, whether made by Blue Ridge Pediatrics, LLP personnel or other health care providers. Other health care providers may have different policies or notices about Manfidentiality and disclosure that apply to your medical information that is created in their offices or at locations other than Blue Ridge Pediatrics, LLP.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your medical information.

- Treatment Alternatives. We may use and disclose medical information to tell you about or recommend different ways to treat you.

- Fundraising Activities. We may use medical information about you to contact you in an effort to raise money for BRP and its operations. Specifically, we may use information about you to target our fundraising efforts. For example, if we are raising money for women's health services, we may focus our fundraising efforts on individuals who have received women's health services from us in the past. We may also disclose medical information to a business partner or a foundation related to BRP so that the business partner or the foundation may contact you in raising money for BRP. We would release limited information about you, such as your name, address and phone number, age and date of birth, gender, your physician, and the dates you received treatment or services at BRP.

If you do not want BRP to contact you for fundraising efforts, you must notify BRP's Privacy Officer in writing. If you have not already done so, we must ask you each time we contact you for fundraising efforts if you wish to opt out of all future fundraising communications. If you do opt out of future fundraising communications, we will no longer disclose your information for fundraising purposes. However, in the future you may let us know in writing that you would like to receive these fundraising communications. Your decision whether or not to receive targeted fundraising materials from us will have no impact on your access to health care services or the treatment we provide to you.

Even if you have opted-out, we may send you non-targeted fundraising materials that are sent out to the general community and are not based on information from your treatment.

- Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. Medical information about you that has had identifying information removed may be used for research without your consent. We also may disclose medical information about you to people preparing to conduct a research project (for example, to help them look for patients with specific medical needs), so long as the medical information they review does not leave BRP. If the researcher will have information about your mental health treatment that reveals who you are, we will seek your consent before disclosing that information to the researcher. Unless we notify you in advance and you give us written permission, we will not receive any money or other thing of value in connection for using or disclosing your medical information for research purposes except for money to cover the costs of preparing and sending the medical information to the researcher.

- Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. This would include persons named in any durable health care power of attorney or similar document provided to us. We may also give information to someone who helps pay for some or all of your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. You can object to these releases by telling us that you do not wish any or all individuals involved in your care to receive this information. If you are not present or cannot agree or object, we will use our professional judgment to decide whether it is in your best interest to release relevant information to someone who is involved in your care or to an entity assisting in a disaster relief effort.

- As Required or Permitted By Law. We may disclose medical information about you when required or permitted to do so by federal, state, or local law.

In response to a court order, warrant, summons, grand jury demand, or similar process;

To comply with mandatory reporting requirements for violent injuries, such as gunshot wounds, stab wounds, and poisonings;

In response to a request from law enforcement for certain information to help locate a fugitive, material witness, suspect, or missing person;

To report a death or injury we believe may be the result of criminal conduct; and

To report suspected criminal conduct committed at BRP facilities.

- Coroners and Medical Examiners. We may release without your consent medical information to a coroner or medical examiner. This may be done, for example, to identify a deceased person or determine the cause of death. We also may release medical information about deceased patients of BRP to funeral directors to carry out their duties.

- National Security and Intelligence Activities. We may release without your consent medical information about you as required by applicable law to authorized federal or state officials for intelligence, counterintelligence, or other governmental activities prescribed by law to protect our national security.

- Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.

- Psychotherapy Notes. Regardless of the other parts of this Notice, psychotherapy notes will not be disclosed outside the BR except as authorized by you in writing or pursuant to a court order, or as required by law. Psychotherapy notes about you will not be disclosed to personnel working within BRP, except for training purposes or to defend a legal action brought against BRP, unless you have properly authorized such disclosure in writing.

- Marketing of Health-Related Products and Services. "Marketing" means a communication for which we receive any sort of payment from a third party that encourages you to use a service or buy a product. Before we may use or disclose your medical information to market a health-related product or service to you, we must obtain your written authorization to do so. The authorization form will let you know that we have been paid to make the communication to you. Marketing does not include: prescription refill reminders or other information that describes a drug you currently are being prescribed, so long as any payment we receive for that communication is to cover the cost of making the communication; face-to-face communications; or gifts of nominal value, such as pens or key chains stamped with our name or the name of a health care product manufacturer. Communications made about your treatment, such as when your physician refers you to another health care provider, generally are not marketing.

- Sale of Medical Information. We cannot sell your medical information without first receiving your authorization in writing. Any authorization form you sign agreeing. to the sale of your medical information must state that we will receive payment of some kind disclosing your information. However, because a "sale" has a specific definition under the law, it does not include all situations in which payment of some kind is received for the disclosure. For example, a disclosure for which we charge a fee to cover the cost to prepare and transmit the information does not qualify as a "sale" of your information.

Is not part of the information that you would be permitted to inspect and copy; or

Has been determined to be accurate and complete.

If we deny your request for an amendment, you may submit a written statement of disagreement and ask that it be included in your medical record.

- Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we have made of medical information about you during the past six years.

To request this list or accounting of disclosures, submit your request in writing to BRP's Privacy Officer and state whether you want the list on paper or electronically. Your request must state a time period that may not be longer than six years. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We may collect the fee before providing the list to you.

- Right to Request Restrictions. Except where we are required to disclose the information by law, you have the right to request a restriction or limitation on the medical information we use or disclose about you. For example, you could revoke any and all authorizations you previously gave us relating to disclosure of your medical information.

We are not required to agree to your request, with the exception of restrictions on disclosures to your health, plan, as described below. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

To request restrictions, make your request in writing to BRP's Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

You may request that we not disclose your medical information to your health insurance plan for some or all of the services you receive during a visit to any BRP location. If you pay the charges for those services you do not want disclosed in full at the time of such service, we are required to agree to your request. "In full" means the amount we charge for the service, not your copay, coinsurance, or deductible responsibility when your insurer pays for your care. Please note that once information about a service has been submitted to your health plan, we cannot agree to your request. If you think you may wish to restrict the disclosure of your medical information for a certain service, please let us know as early in your visit as possible.

- Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, or at another mailing address other than your home address. We will accommodate all reasonable requests. We will not ask you the reason for your request. To request confidential communications, make your request in writing to the Privacy Officer and specify how or where you wish to be contacted.

- Right to a Paper Cop of This Notice. You have the right to a paper copy of this note or any revised notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive

To obtain a paper copy of this notice, request a copy from BRP's Privacy Officer in writing.

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.


Medical History Access-Provides the physician with information about medications the patient is already taking to minimize the number of adverse drug events.

By typing your name below, you are agreeing that Blue Ridge Pediatrics, LLP can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes. You also agree your electronic signature is the legal equivalent of your manual signature on this application.


Your information will be encrypted.