Patient Acknowledgment and Consent

I have been given a copy of Blue Ridge Pediatrics, LLP’s Notice of Privacy Practices effective (Please put date below). I consent to the uses and disclosures of my child’s health information as outlined in the notice.

Patient's Name

Relationship to Patient

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:

Please describe the Representative’s authority to act on behalf of Patient:

MEDICAL ACCESS

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.

Signature of Patient or Representative

Date:

FOR BLUE RIDGE PEDIATRICS’ USE ONLY

If acknowledgment of receipt of the Notice of Privacy Practices is not obtained from the patient or the patient’s representative, please explain your efforts to obtain acknowledgment and the reason you could not obtain it:

Your information will be encrypted.