I hereby give my consent for Drs. Akel and Favale, P.L. to use and disclose protected health information
(PHI) about me to carry out treatment, payment and healthcare operatlons (TPO).
Drs. Akel and Favale, P.L.'s Notice of Privacy Practices provides a more complete description of such uses
I have the right to review the Notice of Privacy Practices prior to signing this consent. Drs. Akel and Favale,
P.L's reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice may be
obtained by forwarding a written request to Drs. Akel and Favale, P.L. Privacy Officer, Anthony Favale at
953 Lane Avenue South, Jacksonville, Florida 32265.
By signing this form, I am consenting to Drs. Akel and Favale, P.L.'s use and disclosure of my PHI to carry out
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, or later decline it, Drs. Akel and Favale, P.L.,
may decline to provide treatment to me.