Patient Registration Form

Main Office
3124 Blue Ridge Road, Suite 102
Raleigh, NC 27612.
Office Number: (919) 782‐0021 Fax Number: (360) 462-5812

Patient's Last Name:

First Name:

Middle Initial:

Patient's Date of Birth:

MOTHER/LEGAL GUARDIAN

Name:

DOB:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cellphone:

Email:

Marital Status:

Single Married Divorced Widowed

FATHER/LEGAL GUARDIAN

Name:

DOB:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cellphone:

Email:

Marital Status:

Single Married Divorced Widowed

Who is the primary caregiver?

Both Father Mother

Other (Please Explain):

If applicable, who has primary custody?

Both Father Mother

*(Please provide legal documentation for any alternative custody arrangements.)

EMERGENCY CONTACT (Other Than Parent)

Name:

Relationship:

Home Phone:

Cell Phone:

INSURANCE INFORMATION

Primary Insurance Company Name:

Insured’s ID Number:

Group Plan Number:

Insured (Policy Holder) First and Last Name:

ADDITIONAL INFORMATION

Race (select one):

American Indian/Alaskan Native Asian Black/African American Native Hawaiian Other Pacific Islander White More than 1 Race Declines to Respond

Ethnicity: (select one):

Hispanic or Latino Not Hispanic or Latino Declines to Respond

Preferred Language:

Pharmacy Name:

Pharmacy Address:

Pharmacy Phone Number:

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.

SIGNED (Patient, or parent if under 18 years of age.)

Date

Initial History Questionnaire

Child’s Full Name:

Preferred Name:

Form Completed by:

Relationship:

Today’s date:

DOB:

Sex

Male Female

Chart#:

SOCIAL HISTORY

Please list those living in the child’s home:

Name:

Relationship:

Birth Date:

Job or School:

Health Problems:

Add new information

Biological Parents:

Married Divorced Single Separated Remarried

If both parents are not living together, who has custody?

Are there any siblings not listed above?

Yes No

Does your child go to daycare?

Yes No

If Yes, where:

Does your child go to school?

Yes No

If Yes, where:

Does anyone in your family smoke (even outside)?

Yes No

If Yes, who?:

Does your family have any pets?:

Yes No

If Yes, what kind:

Do you have smoke alarms in your house?

Yes No

Does your family routinely use seatbelts/carseats?

Yes No

BIRTH HISTORY of your child

Born:

On Time Late Premature

If premature, how early? gestational age (please indicate below) weeks:

At what hospital?

Birth weight: (lbs./ozs)

Did mom have any problems with pregnancy?

Yes No

If Yes, what type of problems:

Was your baby born by Cesarean section?

Yes No

If Yes, why:

Did your baby have any problems after birth?

Yes No

If Yes, what type(s):

Did baby stay in the hospital after mom went home?

Yes No

If Yes, why:

PAST MEDICAL HISTORY

Has your child had any surgery?

Yes No

If Yes, when and why:

Has your child ever been hospitalized?

Yes No

If Yes, when and why:

Does your child have any chronic or serious medical conditions?

Yes No

If Yes, what type(s):

Has your child had any serious accidents or injuries?

Yes No

If Yes, what type(s):

Does your child have any developmental problems?

Yes No

If Yes, what type(s):

Is your child allergic to any medications?

Yes No

If Yes, name of medicine and what type of reaction(s):

Did your child miss or skip any vaccines?

Yes No

If Yes, which ones:

Does your child take any medications on a regular basis?

Yes No

If Yes, what medicine and dosage:

Any over the counter medications on a regular basis?

Yes No

If Yes, what medicine and dosage:

Where did you hear about our practice?

Extra Comments:

FAMILY HISTORY

Any family members (parents, siblings, grandparents, aunts or uncles only) have these?

Active Smoker

Yes No

Relation/Type Problem

Allergies

Yes No

Relation/Type Problem

Anemia/Blood

Yes No

Relation/Type Problem

Asthma

Yes No

Relation/Type Problem

Birth Defect

Yes No

Relation/Type Problem

Bone/Joint probs

Yes No

Relation/Type Problem

Cancer

Yes No

Relation/Type Problem

Deafness

Yes No

Relation/Type Problem

Diabetes

Yes No

Relation/Type Problem

Drug abuse

Yes No

Relation/Type Problem

Eye problems

Yes No

Relation/Type Problem

Genetic Defect

Yes No

Relation/Type Problem

Heart Disease

Yes No

Relation/Type Problem

High Blood-Pressure

Yes No

Relation/Type

High Cholesterol

Yes No

Relation/Type

HIV/AIDS

Yes No

Relation/Type

Immune Problems

Yes No

Relation/Type

Kidney disease

Yes No

Relation/Type

Learning Problems

Yes No

Relation/Type

Liver disease

Yes No

Relation/Type

Lung disease

Yes No

Relation/Type

Mental Illness

Yes No

Relation/Type

Rheumatic Fever

Yes No

Relation/Type

Seizures

Yes No

Relation/Type

Thyroid disease

Yes No

Relation/Type

Tuberculosis

Yes No

Relation/Type

REVIEW OF SYSTEMS

Has your child had any problems with or do you have concerns with any of the following:

Abdominal Pain

Yes No

Comments on “Yes”

Allergy

Yes No

Comments on “Yes”

Anemia

Yes No

Comments on “Yes”

Asthma/wheezing

Yes No

Comment on "Yes"

Attention problems

Yes No

Comments on “Yes”

Bedwetting/soiling

Yes No

Comments on “Yes”

Bladder/kidney probs

Yes No

Comments on “Yes”

Bleeding problems

Yes No

Comments on “Yes”

Broken Bones

Yes No

Comments on “Yes”

Cancer/Leukemia

Yes No

Comments on “Yes”

Cerebral Palsy

Yes No

Comments on “Yes”

Chickenpox

Yes No

Comments on “Yes”

Constipation

Yes No

Comments on “Yes”

Cystic Fibrosis

Yes No

Comments on “Yes”

Dental problems

Yes No

Comments on “Yes”

Developmental probs

Yes No

Comments on “Yes”

Diabetes

Yes No

Comments on “Yes”

Emotional/Behavioral

Yes No

Comments on “Yes”

Genetic Disorders

Yes No

Comments on “Yes”

Hearing problems

Yes No

Comments on “Yes”

Heart, murmurs

Yes No

Comments on “Yes”

High blood pressure

Yes No

Comments on “Yes”

Illicit drug use

Yes No

Comments on “Yes”

Joint Pain/swelling

Yes No

Comments on “Yes”

Learning problems

Yes No

Comments on “Yes”

Liver problems

Yes No

Comments on “Yes”

Many ear infections

Yes No

Comments on “Yes”

Many headaches

Yes No

Comments on “Yes”

Many sore throats

Yes No

Comments on “Yes”

Menstrual problems

Yes No

Comments on “Yes”

Nasal problems

Yes No

Comments on “Yes”

Pneumonia

Yes No

Comments on “Yes”

Seizures

Yes No

Comments on “Yes”

Skin problems

Yes No

Comments on “Yes”

Sleep problems

Yes No

Comments on “Yes”

Speech/Language

Yes No

Comments on “Yes”

Thyroid problems

Yes No

Comments on “Yes”

Vision or Eyes

Yes No

Comments on “Yes”

Any Other Concerns/Extra Comments:

Thank you for your time filling out this form. Please sign below stating to the best of your knowledge the above information is correct.

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 parent/guardian

Date:

I have reviewed the above information with the parent/guardian.

Provider Signature:

Date:

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:

Add New Names

Checkbox list

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:

DISCLAIMER: 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.

Patient Billing and Financial Policy

BLUE RIDGE PEDIATRICS, LLP PATIENT OFFICE AND FINANCIAL POLICY

Please read this information carefully as it explains, in detail, the patient’s office and financial responsibilities of our practice. Any questions regarding this policy may be discussed with our office manager.

BLUE RIDGE PEDIATRICS, LLP PATIENT OFFICE AND FINANCIAL POLICY

Current Information

As a patient at Blue Ridge Pediatrics, LLP, you are required to notify our staff of any changes in your patient information, such as insurance, benefits, employer, patient name, home address and/or contact numbers. You are required to present your current insurance card(s) at each appointment.

Professionalism

Parents and patients are asked to conduct themselves in a professional manner. This office does not tolerate profanity. Anyone displaying abusive behavior will be asked to leave the practice.

Office Visits

At the Blue Ridge location, we offer scheduled appointments between the hours of 7:30 a.m. and 5:30 p.m. on Monday, Tuesday, Thursday, Friday and 9:00 a.m. and 6:00 p.m. on Wednesday. We are available for sick appointments. We are also available on Holidays for emergencies only.

Please consider your child under the care of the Blue Ridge Pediatrics team. It is important for you and your child to be seen by all our physicians at least one time. After you have met all of us, and as appointments permit, we will try to accommodate you if you request a certain physician for both well and sick childcare.

Patients are asked to sit either in the sick room or well room after they check in. Please do not sit in the well room if you are seeing a physician for a sick visit. Once patients are brought to the exam room, they are asked to remain in the room until the physician has completed their exam. Please refrain from standing in the halls. If your child has a rash, please advise the receptionist immediately upon check-in so we can escort you to the treatment room.

If you need a prescription refill, please let the physician know before your appointment is over.

If your appointment is canceled because of an emergency, you will be notified.

Self-referrals

It is important for your primary care physician to be aware of any specialists you/your child may be seeing. If you/your child has been seen by any specialists without a referral from our practice, please be sure to notify your physician. You may be asked to complete a records request form in order for our office to obtain any records from the specialist(s).

Procedures for calling after hours

1. If it is a life-threatening emergency, please call 911.
2. For other medical advice, call 919-782-0021 to reach our voicemail system. Press one (1) for emergencies and a physician will return your call within 15 minutes. Press two (2) if you can wait up to an hour for a call back from the physician.
3. When you leave a message, please be certain to speak slowly and clearly. Be sure to leave your name, patient’s name and age, and a telephone number at which you can be reached.

Forms

Please allow 5 – 7 business days for forms to be completed by a physician. Parents are asked to completely fill out their section(s) of the forms before dropping them off to be completed. There is a minimum charge of $25.00 to complete forms and letters if they are not completed at the time of the appointment.

Inclement Weather

In the chance of inclement weather, please visit our website at www.blueridgepediatrics.com and click on the link to abc11.com for updates and notifications on closings or delays.

Payment at Time of Service

If your insurance plan requires you to pay a co-payment, it will be collected at check-in. Patients who fail to bring their co-pay may be required to reschedule their non-urgent appointment. If you are a self-pay patient or your insurance information cannot be verified prior to your appointment, you will be required to pay in full at the time of service. If your insurance plan requires payment of an annual deductible and/or co-insurance i.e. (80/20 plans), payment will be calculated and due at checkout. We accept cash, personal checks and credit cards. Patient payment plans are also available, if needed, by contacting our billing office prior to your appointment at 919-741-4918.

Cell Phones

We ask that patients refrain from using their cell phones in our office.

Parental Financial Obligations

We are not responsible for mediation between parents. The parent that brings the child to the appointment is responsible for any balances and payments due on the account.

Claims Filing

As a courtesy to our patients, we file claims with your insurance company and also coordinate benefits with secondary payers. You will be responsible in the event the claim is disputed or unpaid.

Our office does not accept discount cards. Patients are expected to pay for their visit at the time of service.

Patient Billing and Collections

Patients that receive statements from our office are expected to remit payment in full upon receipt, unless previous payment arrangements were made with our billing office. If your account must be referred to an outside collection agency for non-payment, a fee equal to 25-30% of the outstanding balance will be added to your account to cover the expense incurred from the agency. The fee percentage varies based on the amount of the outstanding balance. Patients being sent to collections will receive a dismissal letter from the practice giving them 30 days for emergency care and to find another physician. If you receive a billing statement that you do not understand, please contact our billing office at 919-741-4918 for assistance so that the account can be resolved.

No-Shows

Patients that fail to come to their scheduled appointment and do not notify our office of the need to cancel the appointment will be charged a $30.00 no show fee. This charge will be the patient’s responsibility; insurance companies will not pay this charge. Please notify our office 24 hours in advance of a well-child visit and 1 hour in advance for a sick child visit if you cannot keep your appointment. After you incur 3 no shows with in 1 year, you will be asked to leave the practice. Patients are required to arrive 15 minutes prior to their scheduled appointment time. If the patient arrives late it is up to the doctor’s discretion whether the patient can be seen or not. If not, you may be asked to reschedule the appointment.

Returned Checks and Fees

An amount of $30.00 will be charged for a returned check. Personal checks will no longer be accepted from patients that write two bad checks and payments will then need to be made in cash, credit card, or money order.

PATIENT BILLING AND FINANCIAL POLICY

As a courtesy, Blue Ridge Pediatrics, LLP will file a claim for all services to your insurance. Therefore, at
registration, you will be asked for your current insurance information and will be asked to sign a
form verifying the information. It is your responsibility to assure we have your most current insurance
information and to notify us of any changes.

It is also your responsibility as the guarantor to verify that Blue Ridge Pediatrics, LLP is a participating
provider with your insurance company and to be familiar with your plan benefits (i.e. deductibles,
co‐ payments, in and out of network costs).

To summarize, you will be responsible for a bill for the following reasons:

The service is not a covered benefit
Your insurance company requires you to pay deductibles
Co‐payments and/or co‐insurance are required by your insurance company
Missed Appointment/No Show Fees charged for missed appointments

For all patients who must pay their health care bills, we accept cash, check, American Express,
MasterCard, Visa and Discover.

Upon receipt of a billing notice showing your balance due, you are expected to make payment in full.
Please contact our office if you have any questions or need assistance with understanding your bill.

To ensure timely receipt of your account information, please contact us if there is a change to your
billing address.

The parent/guardian or authorized individual that brings the child to an appointment is responsible for
payment of the services rendered.

Patient's Name

Signature

Patient's Date of Birth:

Print Name

Relationship to Patient

Date:

Patient Acknowledgment and Consent

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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

WHO WILL FOLLOW THIS NOTICE

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.

OUR PLEDGE REGARDING MEDICAL INFORMATION

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.

Initial

- 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.

Initial

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.

Date

Patient's Name

Relationship to Patient

Patient's Date of Birth:

DISCLAIMER: 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

Patient's Date of Birth:

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:

Patient Communication Information

In order for us to better communicate with our patients we are asking all patients to fill out this Patient Communication log.

Have you accessed our Patient Portal?

Yes No

If No, Would you like to access our Patient Portal?

Yes No

If Yes, Please print your Email Address here:

When we activate your email address you will receive an email confirmation from us. This will include the link to our portal, your log in and your password. If you forgot your log in and/or password the Receptionist can reset your password for you today

Do you want to reset your log in and password?

Yes No

How would you like us to confirm your appointment? You can select one or both.

By Voice Mail?

Yes No

By Text (SMS) message?

Yes No

What is your preferred phone#?

Is this your Home, Work or Cell Number? (Please select one)

Home Number Work Number Cell Number

What is your preferred language?

English Spanish

Preferred time to call you?

Morning Afternoon Evening

Is there any special information you would like us to add to your child’s account in reference to how we should contact you?

DISCLAIMER: 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.

Patient or Guardian’s Signature:

Today’s Date:

BRP Employee’s Initials:

Scanned:

Entered in ECW:

Your information will be encrypted.