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With my consent, Blue Ridge OB/GYN Associates may use
and disclose protected health information (PHI) about me to carry out
treatment, payment and healthcare operations (TPO). Please refer to the Notice
of Privacy Practices for a more complete description of such uses and
disclosures.
I have the right to review the Notice of Privacy Practices
prior to signing this consent. Blue Ridge OB/GYN Associates reserves the right
to revise the Notice of Privacy Practices at any time. A revised Notice of
Privacy Practices may be obtained by forwarding a written request to Blue Ridge
OB/GYN Associates Privacy Officer at 4420 Lake Boone Trail, Suite 304, Raleigh,
NC 27607.
With my consent Blue Ridge OB/GYN Associates may call my home
or other designated location and leave a message on voice mail or in person in
reference to any items that assist the practice in carrying out TPO, such as
appointment reminders, insurance items and any call pertaining to my clinical
care, including laboratory results among others.
With my consent Blue
Ridge OB/GYN Associates may mail to my home or other designated location any
items that assist the practice in carrying out TPO, such as appointment
reminder cards and patient statements, as long as they are marked Personal and
Confidential.
With my consent Blue Ridge OB/GYN Associates may e-mail
to my home or other designated location any items that assist the practice in
carrying out TPO, such as appointment reminder cards and patient statements. I
have the right to request that Blue Ridge OB/GYN Associates restrict how it
uses or discloses my PHI to carry out TPO.
The practice is not required
to agree to my requested restrictions, but if it does, it is bound by this
agreement.
By signing this form, I am consenting to Blue Ridge OB/GYN
Associates use and disclosure of my PHI to carry out TPO.
I may revoke
my consent in writing except to the extent that the practice has already made
disclosures in reliance upon my prior consent. If I do not sign this consent,
Blue Ridge OB/GYN Associates may decline to provide treatment to me.
(Signature of
Patient or Legal Guardian)
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(Relationship to
Patient) |
(Patient's
Name)
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(Date) |
(Printed Name of
Patient or Legal Guardian) |
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Instructions:
1. Print this form, then fax or mail it.
2. Fax: (919)781-9247
3. Mail Address:
North Raleigh
11001 Durant Road
Suite 100
Raleigh, NC 27614
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