Consent to Treatment

I hereby authorize a health professional(s) of Priority Health Care (PHC) to provide treatment for my health care needs. This treatment may include diagnostic lab work, nurse and doctor visits, prescriptions, referrals to specialty care, health education, and adherence counseling. I have the right to respectful, considerate services at all times. I have the right to ask any questions and to get honest, knowledgeable answers. I understand that any services that may contain alcohol/drug treatment information are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.
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I understand that information discussed with a medical professional is confidential and will not be shared without my written permission except when state law mandates reporting. Those situations include:

1. The patient threatens suicide.
2. The patient threatens harm to another person(s), including, but not limited to, murder, assault, and/or physical harm.
3. The patient reports abuse of the elderly.
4. The patient reports exploitation by a direct service professional.
5. To be released or received to/from the Ryan White Part A Grantee, Ryan White agencies, U.S. Department of Health and Human Services (HRSA), Louisiana Office of Public Health, STD/HIV Program and other agencies for health monitoring purposes. I understand that this information may be faxed, mailed or shared through a network programmatic reporting, coordinating care or services, database systems

I understand that:

1. Priority Health Care is a health care facility with the following hours of operation:

2. Patients may schedule appointments; however same day appointments are also available.
3. Priority Health Care is not a 24-hour medical facility.
4. In the event of an extreme medical emergency, I agree to receive medical care at a facility that provides 24-hour emergency care. 
5. In the event of an after-hour situation, I can call (504) 309-3262 or (504) 509-4800 and someone from the after-hours call center will be able to assist me.

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