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.
I am authorizing Raydel Family Practice, APMC to release any/all medical and billing information to the following family members.