Richard M. Haydel, M.D. | - Scott A. Haydel, M.D. | - Lisa B. Black, M.D. | J. Matthew Watkins, M. D.
A Professional Medical Corporation
502 Barrow Street, Houma, LA 70360


CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

I hereby authorize Haydel Family Practice, APMC to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Haydel Family Practice can refuse to treat me.

I have been informed that Haydel Family Practice, APMC has prepared a notice ("Notice") which more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment and health care operations. I understand that I have the right to review such Notice prior to signing this consent.

I understand that I may revoke this consent at any time by notifying your Privacy Officer, in writing, but if I revoke my consent, such revocation will not affect any actions that Haydel Family Practice took before receiving my revocation.

I understand that Haydel Family Practice has reserved the right to change its privacy practices and that I can obtain such changed notice upon request.

I understand that I have the right to request that Haydel Family Practice, APMC restricts how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health operations. I understand that Haydel Family Practice, APMC does not have to agree to such restrictions, but that once such restrictions are agreed to, my provider must adhere to such restrictions.

Signature of patient or patient's representative
Date
 
Printed name of patient or patient's representative
Relationship to the patient
 
I am authorizing Raydel Family Practice, APMC to release any/all medical and billing information to the following family members.

Name
Relationship to patient