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					                                                             Revised 4/03/03




          Blue Ridge Family Physicians, PLLC
          NOTICE OF PRIVACY PRACTICES
             Effective Date: April 14, 2003




Questions, Concerns, and Complaints are to be directed to:


            Joanna Herath, Privacy Officer
          Blue Ridge Family Physicians, PLLC
            2605 Blue Ridge Road, Suite 300
                  Raleigh, NC 27607
                 Phone: 919-787-3448
                                                                                 Revised 4/03/03
                                      TABLE OF CONTENTS
                                                                                          PAGE

Your Medical Record and the Purpose of this Notice                                          3

Your Rights Regarding Information about You                                                 4

       1. Right to Inspect and Copy                                                         4
       2. Right to Amend                                                                    4
       3. Right to an Accounting of Disclosures                                             5
       4. Right to Request Restrictions on Use and Disclosures of Protected Health          5
       Information About You
       5. Right to Request Confidential Communications From This Office                     6
       6. Right to a Paper Copy of This Notice                                              6

How Blue Ridge Family Physicians May Use and Disclose Information About You                 6

       1. Consent for Disclosure Is Not Needed/Required                                     6
              Treatment                                                                     6
              Payment                                                                       6
              Health Care Operations                                                        7
              Appointment Reminders                                                         7
              Treatment Alternatives                                                        7
              Health Related Products and Services                                          7
              Additional Disclosures                                                        7

       2. Consent for Disclosure Is Needed/Required                                          9
              HIV, STD, Abnormal Test Results, Substance Abuse                              10
              Communications with Family and Friends                                        10
              Release of Test Results and Medications to Third Party                        10
              Minor Children                                                                10
              Power of Attorney                                                             11
              Patient Cannot Be Reached or Is Incapacitated                                 11

       3. Withdrawal of Consent                                                             11

Additional Protections of Protected Health Information That Are Provided Under North        11
Carolina Law or Other Law
               Communicable Diseases                                                        12
               Mental Health, Developmental Disability, Substance Abuse                     12

Change of this Notice                                                                       12

Where to File Complaints                                                                    13

Notice of Privacy Practices Receipt                                                         14




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          YOUR MEDICAL RECORDS AND THE PURPOSE OF THIS NOTICE
Each time you visit Blue Ridge Family Physicians, a record of your visit is made. Typically, this
record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for
future care or treatment. This information often referred to as your medical record, serves as a:

      Basis for planning your care and treatment,
      Means of communication among the many health professionals who contribute to your
       care,
      Legal document describing the care you received,
      Means by which you or a third-party payer can verify that services billed were actually
       provided,
      A tool in educating health professionals,
      A source of data for medical research,
      A source of information for public health officials charged with improving the health of
       this state and the nation,
      A source of data for our planning and marketing,
      A tool with which we can assess and continually work to improve the care we render and
       the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to
ensure its accuracy, better understand who, what, when, where and why others may access your
health information, and make more informed decisions when authorizing disclosures to others.

Although your medical record is the physical property of Blue Ridge Family Physicians, PLLC,
the information belongs to you. You have the right to know about the uses and disclosures of
your protected health information that may be made. Blue Ridge Family Physicians is committed
to responsibly treating and using your protected health information (PHI). This notice describes
information about privacy practices followed by our employees, staff, and other personnel. The
practices described in this notice will also be followed by healthcare providers you consult with
by telephone (when your regular healthcare provider from our office is not available) who
provide “call coverage” for your health care provider.

This notice applies to the information and records we have about your health, health status, and
the healthcare and services you receive at this office. We are required by federal law to maintain
the privacy of protected health information and to provide individuals with the notice of our legal
duties and privacy practice with respect to your information. We will also follow North Carolina
laws that give you more protection of your PHI than the federal law. For example, North
Carolina law gives you more protection of some kinds of PHI including information about
communicable diseases, mental health, developmental disability, and substance abuse. It will tell
you about the ways in which we may use and disclose health information about you. Also, it
describes your rights and our obligations regarding the use and disclosure of that information.
PLEASE REVIEW IT CAREFULLY. You will be asked to sign a form that you received this
Notice. Even if you do not sign this form, we will still provide you treatment. If you have any
questions about this notice, please contact our designated privacy official at 919-787-3448 or by
mail at 2605 Blue Ridge Road, Suite 300 Raleigh, NC 27607. This notice is effective April 14,
2003 and applies to all protected health information as defined by federal and state regulations.


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        YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding information we maintain about you:

1.   Right to Inspect and Copy

You have the right to inspect and copy your health information, such as medical and billing
records, that we use to make decisions about you. You must submit your request in writing.
Please complete a Request to Inspect and Copy Information Form and submit it to our
designated privacy official. A convenient appointment time will be scheduled to give you the
opportunity to review your records. A Blue Ridge employee will be present during your
appointment to assist you. If you request a copy of the information, we may charge a reasonable
fee for the costs of copying, mailing or other associated supplies.

We may deny your request to inspect and/or copy in certain limited circumstances. Under these
circumstances, we will respond to you in writing, stating why we will not grant your request and
describing any rights you have to request review of the denial. If you are denied access to your
health information, you may ask that the denial be reviewed. If such a review is required by law,
we will select a licensed healthcare professional to review your request and our denial. The
person conducting the review will not be the person who denied your request, and we will
comply with the outcome of the review.

2. Right to Amend

If you believe information we have about you is incorrect or incomplete, you may ask us to
amend the information. You have the right to request an amendment as long as the information
is kept by this office. Your request must be in writing. You must also give us a reason for your
request. To request an amendment, complete and submit a Medical Record
Amendment/Correction Form to our designated privacy official. If we accept your request to
amend the information we will make reasonable efforts to inform others of the amendment,
including persons you name who have received PHI and who need the amendment.

We may deny your request for an amendment if it is not in writing or does not include a reason
to support the request. In addition, we may deny your request if you ask us to amend information
that:
    a) We did not create, unless the person or entity that created the information is no longer
       available to make the amendment.
    b) Is not part of the health information that we keep
    c) You would not be permitted to inspect and copy
    d) We believe is accurate and complete.

Under these circumstances, we will respond to you in writing, stating why we will not grant your
request and describing any rights you have to request review of the denial.




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3. Right to an Accounting of Disclosures

You have the right to request an “accounting of disclosures.” This is a list of the disclosures we
made of medical information about you for purposes other than treatment, payment, and
healthcare operations. The list contains the following elements:

      Date of Request
      Purpose of Disclosure (Why information was requested)
      Rule Permission for Disclosure (Is additional patient consent needed?)
      Date of Disclosure
      Information Disclosed (Specific Information Disclosed)
      Recipient (Who Requested Information?)
      Address
      Was PHI Requested? Yes or No
      Other Conditions/Comments

To obtain this list, you must submit and complete the Accounting of Disclosures Form and
submit it to our designated privacy official. It must state a time period, which may be no longer
than six (6) years and may not include dates before April 14, 2003. Your request should indicate
in what form you want the list (for example, on paper or electronically). 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 are not required to include disclosures:
   For your treatment
   For billing and collection of payment for your treatment
   For our health care operation
   Requested by you that you authorized, or which we made to individuals involved in your
       care
   Allowed by law when the use and/or disclosure related to certain specialized government
       functions or related to correctional institutions and in other law enforcement custodial
       situations
   As part of a limited set of information which does not contain information that would
       identify you.

4. Right to Request Restrictions on Use and Disclosures of Protected Health Information
   (PHI) About You

You have the right to request a restriction or limitation on the health information we use or
disclose about you for treatment, payment or healthcare operations. You have the right to
request a limit on the health information we disclose about you to someone who is involved in
your care or the payment for it, like a family member or friend. For example, you could ask that
we not disclose information about a surgery you had. Your request must be in writing. To request
restrictions, you may complete and submit the Restriction on Use and Disclosure of
Information Form to our designated privacy officer.

We are not required to agree to your request. If we do agree, we will comply with your request
unless the information is needed to provide you emergency treatment or disclosure described in
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                                                                                    Revised 4/03/03
pages 7 through 8 of this notice. Under these circumstances, we will respond to you in writing,
stating why we will not grant your request and describing any rights you have to request review
of the denial.

5. Right to Request Confidential Communications From This Office

You have the right to request how and where we contact you. For example, you can ask that we
only contact you at work or by mail.

Your request must be in writing. To request confidential communications, you may complete and
submit the Communication Preference Form to our designated privacy official. We will not
ask you the reason for your request. We will accommodate all reasonable requests. Your
request must specify how or where you wish to be contacted.

6. Right to a Paper Copy of This Notice

You have the right to a paper copy of this notice. You may ask us to give you a copy of this
notice at any time. Paper copies are available at the front desk. Electronic files are also available
on our website at www.blueridgefamilyphysicians.com. Even if you have agreed to receive it
electronically, you are still entitled to a paper copy.


  HOW BLUE RIDGE FAMILY PHYSICIANS MAY USE AND DISCLOSE HEALTH
                    INFORMATION ABOUT YOU

1. Consent for Disclosure Is Not Needed/Required

      Treatment We may use health information about you to provide you with medical
       treatment or services. We may disclose health information about you to doctors, nurses,
       technicians, office staff or other personnel who are involved in taking care of you and
       your health.

       For example, your doctor may be treating you for a heart condition and may need to
       know if you have other health problems that could complicate your treatment. The
       doctor may use your medical history to decide what treatment is best for you. The doctor
       may also tell another doctor about your condition so that doctor can help determine the
       most appropriate care for you.

       Different personnel in our office may share information about you and disclose
       information to people who do not work in our office in order to coordinate your care,
       such as phoning in prescriptions to your pharmacy, scheduling lab work and ordering x-
       rays. Family members and other healthcare providers may be part of your medical care
       outside this office and may require information about you that we have.

      Payment We may use and disclose health information about you so that the treatment
       and services you receive at this office may be billed to and payment may be collected
       from you, an insurance company or a third party. For example, we may need to give your
       health plan information about a service you received here so your health plan will pay us

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                                                                               Revised 4/03/03
    or reimburse you for the service. We may also tell your health plan about a treatment you
    are going to receive to obtain prior approval, or to determine whether your plan will
    cover the treatment.

   Healthcare Operations We may use and disclose health information about you in order
    to run the office and make sure that you and our other patients receive quality care. For
    example, we may use your health information to evaluate the performance of our staff in
    caring for you. We may also use health information about all or many of our patients to
    help us decide what additional services we should offer, how we can become more
    efficient, or whether certain new treatments are effective. We may also disclose PHI for
    the healthcare operations of any organized health care arrangement in which we
    participate. An example of an organized health care arrangement is the joint care
    provided by a hospital and the physicians who see patients at the hospital.

   Appointment Reminders We may contact you as a reminder that you have an
    appointment for treatment or medical care at the office. If you do not wish to receive
    appointment reminders, you can request not to receive this service. We will need this
    notice in writing.

   Treatment Alternatives We may tell you about or recommend possible treatment
    options or alternative that may be of interest to you.

   Health Related Products and Services We may tell you about health-related products or
    services that may be of interest to you.

   Additional Disclosures We may use or disclose health information about you without
    your permission for the following purposes, subject to all applicable legal requirements
    and limitations:

       To Avert a Serious Threat to Health or Safety We may disclose health information
        about you in limited circumstances to prevent a serious threat to your health and
        safety or the health and safety of the public or another person. This disclosure can
        only be made to a person who is able to help prevent the threat.

       Required by Law We may use and disclose PHI as required by federal, state, or local
        law to the extent that the use or disclosure complies with the law and is limited to the
        requirements of the law.

       Abuse, Neglect, or Domestic Violence We may disclose PHI in certain cases to
        proper government authorities if we reasonably believe that a patient has been a
        victim of domestic violence, abuse, or neglect.

       Research We may use and disclose health information about you for research project
        that are subject to a special approval process. We will ask you for your permission if
        the researcher will have access to your name, address, or other information that
        reveals who you are, or will be involved in your care at the office.



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                                                                           Revised 4/03/03
   Organ and Tissue Donation If you are an organ donor, we may release health
    information to organizations that handle organ procurement or organ, eye or tissue
    transplantation or to an organ donation bank, as necessary to facilitate such donation
    and transplantation.

   Specialized Government Functions Under certain conditions, we may disclose PHI:

    o For certain military and veteran activities, including determination of
      eligibility for veterans benefits and where deemed necessary by military
      command authorities;
    o For national security and intelligence activities;
    o To help provide protective services for the President of the United States and
      others;
    o For the health or safety of inmates and others at correctional institutions or
      other law enforcement custodial situations or for general safety and health
      related to correctional facilities.

   Workers’ Compensation We may release health information about you for workers’
    compensation or similar programs as authorized by workers’ compensation laws or
    other similar programs that provide benefits for work-related injuries or illness.

   Public Health Activities We may use or disclose PHI to public health authorities or
    other authorized persons to carry out certain activities related to public health,
    including the following activities:

    o To prevent or control disease, injury, or disability;
    o To report disease, injury, birth or death;
    o To report child abuse or neglect;
    o To report reactions to medications or problems with products or devices
      regulated by the federal Food and Drug Administration (FDA) or other
      activities related to qualify, safety, or effectiveness of FDA-regulated
      products or activities;
    o To locate and notify persons of recalls of products they may be using;
    o To notify a person who may have been exposed to a communicable disease in
      order to control who may be at risk of contracting or spreading the disease;
      or
    o To report to your employer, under limited circumstance, information related
      primarily to workplace injuries or illnesses, or workplace medical
      surveillance.

   Health Oversight Activities We may disclose health information about you to a
    health oversight agency for audits, investigations, inspections, or licensing purposes.
    These disclosures may be necessary for certain state and federal agencies to monitor
    the healthcare system, government programs, and compliance with civil rights laws.

   Lawsuits, Disputes, and other Legal Proceedings We may use or disclose PHI
    when required by a court or administrative tribunal order. We may also disclose PHI
    in response to subpoenas, discovery request, or other required legal process when


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                                                                                 Revised 4/03/03
           efforts have been made to advise you of the request or to obtain an order protecting
           the information requested.

          Law Enforcement Under certain conditions, we may disclose PHI to law
           enforcement officials for the following purposes where the disclosure is:

           o About a suspected crime victim if, under certain limited circumstances we
             are unable to obtain a person’s agreement because of incapacity or
             emergency;
           o To alert law enforcement of a death that we suspect was the result of
             criminal conduct;
           o Required by law;
           o In response to a court order, warrant, subpoena, summons, administrative
             agency request, or other authorized process;
           o To identify or locate a suspect, fugitive, material witness, or missing person;
           o About a crime or suspected crime committed at our office; or
           o In response to a medical emergency not occurring at the office, if necessary
             to report a crime, including the nature of the crime, the location of the crime
             or the victim, and the identity of the person who committed the crime.

          Coroners, Medical Examiners and Funeral Directors We may release health
           information to a coroner or medical examiner, as authorized by law, so that they may
           carry out their jobs. This may be necessary, for example, to identify a deceased
           person or to determine cause of death.

          Disclosures Required by HIPAA Privacy Rule We are required to disclose PHI to
           the Secretary of the United States Department of Health and Human Services when
           requested by the Secretary to review our compliance with the HIPAA Privacy Rule.
           We are also required in certain cases to disclose PHI to you upon your request to
           access PHI or for an accounting of certain disclosures of PHI about you.

          Incidental Disclosures We may use of disclose PHI incident to a use or disclosure
           permitted by the HIPAA Privacy Rule so long as we have reasonable safeguarded
           against such incidental uses and disclosures and have limited them to the minimum
           necessary information.

          Limited Data Set Disclosures We may use or disclose a limited data set (PHI that
           has certain identifying information removed) for the purposes of research, public
           health, or health care operations. This information may only be disclosed for
           research, public health, and health care operations purposes. The person receiving the
           information must sign and agreement to protect the information.

2. Consent for Disclosure Is Needed /Required

We will not use or disclose your health information for any purpose other than those identified in
the previous sections without your specific, written authorization. There are two forms that can
be completed and submitted: Authorization to Use and Disclose Health Information Form and
the Patient Proxy/Representative Authorization Form. We will not use or disclose your
information in these situations:
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                                                                                Revised 4/03/03


   HIV, STD, Substance Abuse Information Some test results can only be discussed in
    face-to-face situations – HIV tests, sexually transmitted diseases, abnormal results etc.
    These results will not be discussed with a patient or any other third party over the phone.
    If we have HIV or substance abuse information about you, we cannot release that
    information to a third party without a special signed, written authorization (different than
    the Authorization and Consent mentioned above) from you. In order to disclose these
    types of records for purposes of treatment, payment, or healthcare operations, we will
    have to have both your signed Consent and a special written Authorization that complies
    with the law governing HIV or substance abuse records.

   Communications to Family and Friends We may disclose health information about you
    to your family members or friends if we obtain your written agreement (Patient Proxy
    Representative Authorization Form) to do so or if we give you an opportunity to object
    to such a disclosure and you do not raise objection. We may also disclose health
    information to your family or friends if we can infer from the circumstances, based on
    our professional judgment that you would not object. For example, we may assume you
    agree to our disclosure of your personal health information to your spouse when you
    bring your spouse with you into the exam room during treatment or while treatment is
    discussed.

   Release of Test Results and Medications to Third Party For the protection of your
    private health information, this office requires written permission to release test results,
    copies of medical records, and billing history to your spouse or other family members. To
    authorize the release of this information to a third party, you may complete and submit
    the Patient Proxy/Representative Authorization Form to our designated privacy officer.
    Documentation of your consent will be made in your record. Your consent can be
    revoked at any time. Most will not be discussed over the phone with anyone other than
    yourself without written permission. Again, HIV, STD, and Substance Abuse information
    will not be discussed over the telephone at all. We may use our professional judgment
    and experience with common practice to make reasonable decision about when it is in
    your best interest to allow another person to act on your behalf.

   Minor Children Minors must have written permission from parents for treatment.
    Verbal consent will suffice in an emergency, however, the parent’s/guardian’s permission
    must be documented in the patient’s chart. Custodial parents of minors may authorize
    another adult to consent to treatment for their children. The North Carolina General
    Statute contains a non-exclusive form that may be used for this purpose, at §32A-34. A
    form of this kind is typically used by: Parents whose children are routinely kept by
    another adult (such as a grandparent or babysitter), parents who are planning to be out-of-
    town or otherwise unavailable for a defined period. The standard form may be altered to
    limit the agent’s authority to a certain period or to exclude certain procedures or
    situations from the agent’s authority. In an emergency situation, treatment will not be
    delayed because of lack of this authorization. Some practices typically see minor patients
    who are old enough to come to the office alone. Minors will occasionally be dropped off
    at a practice for treatment while the parent is otherwise occupied. If either of these
    situations is anticipated, the parent or guardian may sign a form in advance of the
    appointment authorizing the physicians or practice to treat the minor in the parent’s

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       absence. In an emergency situation, treatment should not be delayed because of a lack of
       this authorization. Parents of minors have access to charts until child turns 18.
       Communications with Patient 18 yrs old and over are only directed to the patient unless
       directed otherwise. Minors can consent to treatment in certain situations. North Carolina
       statute (N.C.G.S. §90-21.5) identifies four areas in which patients under 18 may give
       consent for treatment for themselves: prevention, diagnosis, and treatment of venereal
       disease, prevention, diagnosis, and treatment of pregnancy (not including termination of
       pregnancy), prevention, diagnosis, and treatment of substance abuse, prevention,
       diagnosis, and treatment of emotional disturbance (not including admission to an in-
       patient facility). According to North Carolina General Statute §7A-721, an emancipated
       minor is a person under eighteen years of age who: is married or has been emancipated
       by judicial action. An emancipated minor can consent to any medical or dental treatment
       for himself or herself independent of a parent or guardian. Note that a minor does not
       become emancipated by moving out of his or her parents’ house or by having a baby.

      Power of Attorney If family member has power of attorney we must have a copy on file
       in order to comply with the patient representative’s requests.

      Patient is Unreachable or Incapacitated In situations where you are not capable of
       giving consent (because you are not present, we are unable to reach you, or you are
       incapacitated by a medical emergency), we may, using our professional judgment,
       determine that a disclosure to your family member or friend is in your best interest. In
       that situation, we will disclose only health information relevant to the person’s
       involvement in your care or payment related to your care.

3. Withdrawal of Consent

If you give us Authorization to use or disclose health information about you, you may revoke
that Authorization, in writing, at any time. Please complete the Withdrawal of Consent Form
and submit it to our designated privacy officer. If you revoke your Authorization, we will no
longer use or disclose information about you for the reasons covered by your written
Authorization, but we cannot take back any uses or disclosures already made with your
permission.

Your revocation will be effective when we receive it, but it will not apply to any uses and
disclosures that occurred before that time. If you do revoke your Consent to the extent we would
not be permitted to use or disclose information for purposes of treatment, payment or healthcare
operations, we may choose to discontinue providing you with healthcare treatment and services.

 ADDITIONAL PROTECTIONS OF PROTECTED HEALTH INFORAMTION THAT
     ARE PROVIDED UNDER NORTH CAROLINA LAW OR OTHER LAW

Up to this place in this Notice, we have been describing the uses and disclosure of PHI that we
may make under the HIPAA Privacy Rule. However, HIPAA does not change some North
Carolina laws or other laws that are more protective of patient privacy. This section describes
these other laws that give you more protection in certain circumstances or with respect to certain
kinds of PHI. Aside from these laws, we believe that HIPAA generally is consistent with North
Carolina and other privacy laws and requirements. As government agencies offer more guidance

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on HIPAA, state, and other laws, we will make appropriate changes to our privacy practices and
this Notice.

1. Communicable Diseases

State law limits when communicable disease information may be disclosed. In certain situations,
state law permits disclosure of communicable disease information that relates to you without
your authorization. “Communicable diseases” are generally illnesses that can be transmitted
from one person to another, such as HIV/AIDS, tuberculosis, hepatitis, and syphilis. North
Carolina law allows disclosures of communicable disease information in the following
circumstances:

      to health care personnel for the purpose of providing you treatment;
      to the appropriate government agency responsible for the control of communicable
       diseases and conditions;
      if a court orders the disclosure;
      if we receive a subpoena that requires a disclosure;
      to the health inspector during an inspection of our offices; and
      if the disclosure is for statistical purposes and there is no way that you can be identified.

We must disclose your HIV status to the physician treating a health care worker who was
exposed to your blood or body fluids. We must notify the local health director if we have reason
to believe that you are HIV positive and are not following any of the control measures that have
been given to you by the local health director.

2. Mental Health, Developmental Disability, and Substance Abuse

Under North Carolina law, there are limitations on the disclosure of information about you that
relates to your being served by a facility that provides services for the care, treatment,
habilitation, or rehabilitation of the mentally ill, the developmentally disabled, or substance
abusers without your authorization. We may disclose this kind of information only as permitted
or required by North Carolina law.

Federal law and regulations do not protect any information about a crime committed by a patient
either at the program or against any person who works for the program or about any threat to
commit such a crime. Federal laws and regulations do not protect any information about
suspected child abuse or neglect from being reported under State law to appropriate State or local
authorities.

                                CHANGES TO THIS NOTICE

We reserve the right to change this notice, and to make the revised or change notice effective for
medical information we already have about you as well as any information we receive in the
future. We must change our policies and procedures as necessary and appropriate to comply
with changes in law. We will post a summary or the current notice in the office with its effective
date in the top right hand corner. An updated copy will also be located at our website
www.blueridgefamilyphysicians.com . You are entitled to a copy of the notice currently in
effect.

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                                         COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our office or
with the Secretary of the Department of Health and Human Services. To file a complaint with
our office, please complete and submit a Complaint Form to our privacy official. Our Privacy
Official may be contacted by phone (919-787-3448) or by mail at:

Privacy Official
Blue Ridge Family Physicians
2605 Blue Ridge Road, Suite 300
Raleigh, NC 27607

You may also choose to file your complaint with the Office for Civil Rights, U.S. Department of
Health and Human Services. The address for the OCR is listed below:

Office for Civil Rights
U.S. Department of Health and Human Services
209 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201

There will be no retaliation for filing a complaint with either the Privacy Official or the Office of
Civil Rights (OCR).




                              Blue Ridge Family Physicians, PLLC
                               Notice of Privacy Practices Receipt

                       Please read and sign this form acknowledging you
                            received the Notice of Privacy Practices.
                                          Thank you.


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I acknowledge that I was provided with the Notice of Privacy Practice of Blue Ridge
Family Physicians.

Name of Patient: ______________________________________________
Signature of Patient: ___________________________________________
Date: _______________________________________________________
Patient’s Date of Birth: _________________________________________
Patient #: ____________________________________________________


For Personal Representative of the Patient (if applicable)
Name of Personal Representative: ____________________________________________
Describe Personal Representative Relationship:
______________________________________________________________________________
__________________________________________________________________
Signature of Personal Representative: _________________________________________
Date: ___________________________________________________________________


For Practice Use Only:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


____________________________________            ______________________________
Signature of Practice Employee                  Date




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Description: North Carolina Law and Physicians Orders document sample