Richard E. Layton, M.D. Banned
from Using Chelation Therapy

Stephen Barrett, M.D.


In 2013, the Maryland State Board of Physicians charged Richard E. Layton, M.D. with failing to meet appropriate standards of care in his management of seven pediatric patients. The consent order (shown below) indicates that the board was concerned with his inappropriate use of (a) chelation therapy, (b) intravenous glutathione, (c) intravenous secretin, (d) ketoconazole (an antifungal medication), (e) Zithromax (an antibiotic), (f) methyl B2 injections, (g) low-dose allergy injections, (h) intravenous vitamin C, (i) other dietary supplements, and (j) various dietary restrictions. Six of the patients had been diagnosed as autistic. The seventh patient began seeing Layton at age 7 months because the parents were concerned that he might be autistic, but a pediatric neurologist later determined that he was not. The case was settled with a consent order under which Layton was (a) reprimanded, (b) fined $5,000, (c) permanently barred from administering chelation therapy, (d) permanently barred from using antifungal drugs for non-approved purposes, and (e) ordered to use a board-approved consent form whenever he proposed to use a nonstandard "alternative" or "complementary" treatment. Layton, who practices pediatrics, was listed for more than ten years in the "Clinical Registry" of Defeat Autism Now! (DAN!), a fringe organization that advocated chelation therapy and many other dubious "biochemical" approaches.


IN THE MATTER OF

RICHARD E. LAYTON, M.D.

Respondent

License Number: 008413

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BEFORE THE

MARYLAND STATE

BOARD OF PHYSICIANS

Case Number: 2012-0820


CONSENT ORDER

On May 30, 2013, the Maryland State Board of Physicians (the "Board"), charged Richard E. Layton, M.D. (the Respondent"), License Number 008413, under the Maryland Medical Practice Act (the "Act"), Md. Health Occ. Code Ann. ("Health Occ.") § 14-404(a).

The pertinent provision of the Act provides the following:

(22) Fails to meet appropriate standards as determined by appropriate peer review for the delivery of quality medical and surgical care performed in an outpatient surgical facility, office, hospital, or any other location in this State[.]

On September 4, 2013, a Disciplinary Conference for Case Review ("DCCR") was convened in this matter. Based on negotiations occurring as a result of this DCCR, the Respondent agreed to enter into this Consent Order, consisting of Findings of Fact, Conclusions of Law, and Order.

I. FINDINGS OF FACT

The Board finds the following:

Background

1. At all times relevant, the Respondent was licensed to practice medicine in the State of Maryland. The Respondent was originally licensed to practice medicine in Maryland on August 14, 1970, and his current license is scheduled to expire September 30, 2014.

2. The Respondent is board-certified in pediatric medicine.

3. At all times relevant, the Respondent's practice involved "mainstream and complementary" medicine; for the past 25 years he has treated both children and adults. According to the Respondent's description, his pediatric patients included children with developmental delays including Autism Spectrum Disorder ("ASD"), digestive complaints, recurrent infections and allergies. The Respondent's adult patients presented with complaints involving fatigue, digestion and headaches.

4. On or about May 21, 2012, the Board received a complaint from an attorney who had submitted a deposition from a court case. The attorney alleged the Respondent had been misprescribing medications to pediatric patients.

5. On or about May 22, 2012, based on the complaint, the Board notified the Respondent it had opened a preliminary investigation, and requested a response to the allegations.

6. On or about June 4, 2012, the Respondent submitted a written response to the allegations.

7. By letter dated July 19, 2012, the Board notified the Respondent it had opened a full investigation.

8. On or about September 17, 2012, the Board's staff sent the Respondent a copy of the complaint and requested responses to questions relating to the Respondent's practice of autism, and the Respondent submitted a written response.

9. On or about November 20, 2012, the Board transmitted ten patient records to Permedion, a formal peer review organization, for the purpose of conducting a peer review. Permedion assigned the peer review to two physicians board-certified in pediatric medicine, the results of which are set forth in pertinent part below.

10. On or about January 18, 2013, the Board's staff transmitted copies of the redacted peer review reports to the Respondent, who submitted a supplemental response to the Board for its consideration.

Patient-Related Findings

Patient 1

11. Patient 1, a male patient, initially saw the Respondent for care on January 7, 2009. The Respondent saw Patient 1 for approximately 45 office visits through July 26, 2012.

12. The Respondent documented that Patient 1 had a history of ASD, recurrent strep and allergies.

13. Prior to and during the Respondent's care of Patient 1, he was also seen by an alternative medical physician located in Texas (Dr. J) who had provided Patient 1 with intravenous ("IV") chelation therapy1 and other alternative medications including but not limited to: Glutathione,2 Vitamin C, nasal oxytocin3 and secretin.4

1Chelation therapy is the administration of chelating agents to remove heavy metals from the body.
2Tripeptide (three amino acids) produced by the liver.
3A hypothalamic hormone which has uterine-contracting and milk-releasing actions.
4A hormone secreted by the small intestine.

14. From approximately February 2011 through at least July 2012, Patient 1's family also consulted with another physician located in Florida, Dr. L, regarding the care of Patient 1's ASD.

15. The standard of quality medical care in the treatment of ASD includes behavioral modification/intervention, specialized educational services, and psychosocial supports. Medications are used to treat specific symptoms and may include antianxiety medications, sleeping medications, ADHD (attention deficit hyperactivity disorder) medications and SSRI (selective serotonin re-uptake inhibitors) medications.

16. During Patient 1's initial visit, the Respondent administered three medications by IV: Glutathione, Vitamin C and secretin, and continued these medications through most of Patient 1's visits.

17. Patient 1 frequently received Zithromax (an antibiotic), ketoconazole,5 nasal oxytocin and Methyl B 12 to Patient 1 while under the care of the Respondent.6

5A synthetic antifungal and antiandrogenic drug used to prevent and treat fungal skin infections.
6The Respondent noted in his response to the Board that "all the supplements and medications have been ordered by other physicians" and that he basically functioned as a "team player." He did however, administer the medications, oversee the care of Patient 1, and arrange for the parents to order certain medications through compounding pharmacies. Additionally, he conferred with the consulting physicians with regard to the dosages.

18. The Respondent frequently prescribed the Zithromax to Patient 1 without any documented evidence of a bacterial infection.

19. The Respondent frequently prescribed ketoconazole to Patient 1 without any evidence documented in Patient 1's record that he had a yeast or fungal infection. On some occasions he would document, "per Dr. [J]." On May 10, 2010 for example, he prescribed 30 tablets with three refills.

20. Prolonged use of ketoconazole has the potential for serious harm including hepatic toxicity. The standard of quality care requires that there be a documented need for the medication, that patients receiving this drug be informed of the risk and be closely monitored.

21. The Respondent failed to adequately monitor Patient 1 during the administration of ketoconazole.

22. In August 2009, Patient 1's parents asked the Respondent to continue Patient 1's chelation therapy. The Respondent had never before treated a patient with chelation therapy.7

7The Respondent refers in Patient 1's records to a second patient, Patient A, to whom he intended to administer chelation therapy.

23. Chelation therapy, an alternative therapy, not approved by the Food and Drug Administration ("FDA"), is not considered to be the standard of quality medical care in the treatment of ASD.

24. Chelation therapy has potential side effects that include kidney failure, arrhythmias, allergic reactions and cardiac arrest secondary to hypocalcemia.

25. There is no accepted evidence that shows that chelation therapy alters the outcome for children with autism. Both traditional medicine (the American Medical Association and the American Academy of Pediatrics) and the National Center for Complementary and Alternative Medicine have stated that chelation and secretin are of no proven benefit in the treatment of children with ASD.

26. The Respondent initially administered the IV chelation based on dosages he received in e-mail communications from Dr. J's non-physician staff.

27. Beginning in August 2009 and continuing through July 26, 2012, the Respondent administered or oversaw IV chelation therapy (with either DMPS8 or calcium EDTA) to Patient 1, approximately every two to three weeks.

8DMPS stands for Dimercaptopropanesulfonic acid and EDTA stands for Ethylenediaminetetraacetic acid; they are both chelating agents. DMPS is not approved by the U.S. Food and Drug Administration ("FDA") and is considered an experimental drug in the United States.

28. On March 28, 2011, the Respondent ordered IV home infusions for Patient 1 to include secretin, glutathione, vitamin C, calcium EDTA and DMPS.

29. On some occasions, the Respondent documented difficulties with the infusion and with Patient 1's veins.

30. The Respondent failed to document a physical examination of Patient 1, and only documented his height and weight on one occasion (August 3, 2010).

31. The Respondent failed to document Patient 1's vital signs prior to or after administering IV chelation therapy.

32. The Respondent failed to include signed informed consent forms in Patient 1's record indicating that Patient 1's parents were aware of the risks of the alternative therapies he was prescribing.

33. The Respondent failed to meet appropriate standards for the delivery of quality medical care of Patient 1 in violation of Health Occ. § 14-404(a)(22).

Patient 2

34. Patient 2, a male, saw the Respondent for severe autism on approximately four occasions from December 2011 through September 2012.

35. Patient 2 had no speech capacity, constipation, severe behavioral problems and a sleep disorder.

36. On the initial intake form, Patient 2's father documented his son was diagnosed with autism and he "suspect[s] that he has heavy metals in his body." He sought the Respondent's care for "DAN" treatment.9

9DAN! was an acronym for "Defeat Autism Now!" and was a community of practitioners who cared for children on the autism spectrum; the organization has changed its name.

37. The Respondent conducted stool and hair analyses and treated Patient 2 with a variety of supplements including probiotics, GABA,10 lgG 2000,11 Yeast Aid, Methyl B12 injections and Enhansa.12

10GABA, a neurotransmitter, stands for gamma aminobutyric acid.
11An immunoglobulin supplement.
12Enhana consists mainly of curcumin, the main ingredient in turmeric.

38. On March 12, 2012, the Respondent started Patient 2 on ketoconazole 200 mg. daily (he provided him with six refills on the prescription). Patient 2's stool had evidence of candida; however, he had no documented signs of infection.

39. Prolonged use of ketoconazole has the potential for serious harm including hepatic toxicity. The standard of quality care requires that there be a documented need for the medication, that patients receiving this drug be informed of the risk and be closely monitored.

40. The Respondent failed to conduct a physical examination of Patient 2 prior to prescribing the ketoconazole.

41. The Respondent ordered blood testing on only one occasion for liver enzymes, on June 4, 2012.

42. The Respondent failed to adequately monitor · Patient 2 when prescribing ketoconazole.

43. On June 4, 2012, the Respondent began prescribing chelating (DMPS) suppositories.

44. Chelation therapy, an alternative therapy, not approved by the Food and Drug Administration ("FDA") is not considered to be the standard of quality medical care in the treatment of ASD.

45. Chelation therapy has potential side effects that include kidney failure, arrhythmias, allergic reactions and cardiac arrest secondary to hypocalcemia.

46. There is no accepted evidence that shows that chelation therapy or antifungal therapy alters the outcome for children with autism. Neither chelation nor antifungal therapy are accepted treatments for ASD by either traditional medicine (the American Medical Association and the American Academy of Pediatrics) or the National Center for Complementary and Alternative Medicine.

47. On September 4, 2012, Patient 2's parents notified the Respondent they had taken him to the emergency room for out of control behaviors that had worsened since July. They were concerned his behaviors had been affected by "something added over last visit." The Respondent documented a four week plan to stop several supplements and the chelating suppositories.

48. The Respondent failed to include signed informed consent forms in Patient 2's record indicating that Patient 2's parents were aware of the risks of the alternative therapies he was prescribing.

49. The Respondent failed to meet appropriate standards for the delivery of quality medical care of Patient 2 in violation of Health Occ. § 14-404(a)(22).

Patient 3

50. Patient 3, a male, had a history including ASD. Patient 3 began seeing the Respondent on October 6, 2011. He had seen numerous alternative providers prior to being evaluated by the Respondent, and two additional physicians continued to provide care for him (Ors. R and K).

51. Patient 3's physicians referred Patient 3 to the Respondent for low dose allergen therapy ("LDA").

52. LDA is an alternative form of allergy injections, including a combination of antigens with chondroitin sulfate and beta glucuronidase. LDA is not approved by the FDA for the treatment of allergies or ASD.

53. LDA is not an accepted treatment for ASD.

54. The Respondent treated Patient 3 on four occasions with LDA: October 26, 2011, November 22, 2011, January 19, 2012 and March 22, 2012.

55. The Respondent failed to conduct allergy testing prior to administering the LDA.

56. Since the FDA does not regulate LDA it must be compounded individually. The composition must be specified for each patient use.

57. The Respondent failed to document a specific prescription for Patient 3 for the LDA.

58. The Respondent failed to include a signed informed consent form in Patient 3's record indicating that Patient 3's parents were aware of the risks of the alternative therapies he was prescribing. 59. The Respondent failed to meet appropriate standards for the delivery of quality medical care of Patient 3 in violation of Health Occ. § 14-404(a)(22).

Patient 4

60. Patient 4, a male, is Patient 3's twin brother. Patient 4 had a history of ASD.

61. Patient 4's physicians referred Patient 4 to the Respondent for LDA.

62. LDA is not an accepted treatment for ASD.

63. The Respondent treated Patient 4 on four occasions with LDA: October 16, 2011, November 22, 2011, January 19, 2012 and March 22, 2012.

64. Patient 4 failed to show any improvement with the LDA treatments, and the Respondent discontinued them after the fourth visit.

65. The Respondent failed to conduct allergy testing prior to administering the LDA.

66. Since the FDA does not regulate LDA it must be compounded individually. The composition must be specified for each patient use.

67. The Respondent failed to document a specific prescription for Patient 4 for the LDA.

68. The Respondent failed to include a signed informed consent form in Patient 4's record indicating that Patient 4's parents were aware of the risks of the alternative therapies he was prescribing.

69. The Respondent failed to meet appropriate standards for the delivery of quality medical care of Patient 4 in violation of Health Occ. § 14-404(a)(22).

Patient 5

70. Patient 5, a male, had a history of ASD with severe self-injurious behaviors ("SIB") including eye injuries (detached retinas). Patient S's parents brought him to the Respondent for alternative therapy; he had been on multiple psychotropic medications without success.

71. The Respondent conducted three in-person visits of Patient 5, beginning on October 27, 2011. Additional encounters included telephone and e-mail consultations. The last documented encounter was a telephone consultation on January 17, 2012.

72. The Respondent treated Patient 5 with various supplements, dietary changes, Zithromax, LDA treatments and Lamictal.13

73. The Respondent elicited a detailed history during his initial visit, but failed to conduct a physical examination of Patient 5.

74. On October 27, 2011, the Respondent prescribed Lamictal to Patient 5. 75. The Respondent initially treated Patient 5 with LDA on October 29, 2011 ("LDA #1 "). He failed to conduct any allergy testing prior to injecting Patient 5 with the LDA treatment.

76. LDA is not an accepted treatment for ASD.

77. Since the FDA does not regulate LDA it must be compounded individually. The composition must be specified for each patient use.

78. The Respondent failed to document a specific prescription for Patient 5 for the LDA.

79. On December 11, 2011, Patient 5's father sent an e-mail to the Respondent noting that Patient 5 had shown no improvement and had worsened in some areas. The Respondent recommended stopping the Lamictal.

80. On December 19, 2011, the Respondent documented that LDA #1 had helped for one week. Patient 5's school was reporting difficulty with his management. The Respondent administered a second LDA treatment on this date. He also provided Patient 5 with a prescription for Zithromax with one refill.

13Medication commonly used in the treatment of seizure disorders and bipolar disorders.

81. On December 29, 2011, Patient 5's father stated in an e-mail to the Respondent that Patient 5 had experienced increased agitation, outbursts and SIB after giving Patient 5 a six pill package of Zithromax noted in ¶80.14

14The Respondent documented that Patient 5's parents had administered the Zithromax two weeks early, and that "may have affected LDA #2."

82. On January 4, 2012, the Respondent participated in a conference call with Patient 5's school staff. There had been an increase in Patient 5's aggression including throwing furniture, destroying property and SIB. Patient 5's school recommended an in-patient stay based on safety and learning problems. The Respondent recommended that Patient 5 be provided a homebound instructor as he needed to be with his parents.

83. On January 17, 2012, the Respondent documented a telephone consultation with Patient 5's father, stating in part that Patient 5 had been discharged from school, that he had discussed two new supplements (VSL315 and methylfolate16) and that the family was considering a trip to Africa. The Respondent documented that the plan included VSL3, "if stable" methylfolate and zinc. The Respondent mailed a prescription for methylfolate with six refills issued to Patient 5. The Respondent had further documented that the plan included "LDA" and consideration of additional supplements on the next visit scheduled for February 14, 2012.

15A probiotic preparation.
16A form of B vitamin
.

84. The Respondent failed to include signed informed consent forms in Patient 5's record indicating that Patient 5's parents were aware of the risks of the alternative therapies he was prescribing.

85. On February 29, 2012, Patient 5's father sent the Respondent an e-mail telling him that Patient 5 had died while in Africa.

86. The Respondent failed to meet appropriate standards for the delivery of quality medical care of Patient 5 in violation of Health Occ. § 14-404(a)(22).

Patient 6

87. Patient 6, a male, began seeing the Respondent on November 1, 2011 for ASD, allergies and a history of urticaria (hives) with certain foods. The records reviewed reflected visits through August 14, 2012.

88. The Respondent treated Patient 6 with dietary restrictions, and supplements including Methyl 812 injections and LDA (by inhalant). Additionally, the Respondent prescribed Prozac (SSRI antidepressant) for obsessive compulsive type behaviors.

89. LDA is not an accepted treatment for ASD.

90. On November 1, 2011, the Respondent began treating Patient 6 with LDA, and continued treating him with LDA on several occasions through August 14, 2012.

91. On December 29, 2011, the Respondent documented that Patient 6 had no side effects from the LDA, but had "no obvious benefits."

92. On February 22, 2012, the Respondent prescribed Singulair granules17 with six refills.

17Used in the treatment of allergies.

93. On February 23, 2012, Patient 6's mother e-mailed the Respondent stating that Patient 6 had been very quiet, had cried for an extended period at school and was subsequently difficult to calm down. She was questioning whether some of the supplements would have caused this behavior. She also stated that his eyes were red and swollen and asked whether this might be an "allergy reaction."

94. On June 8, 2012, the Respondent documented in an e-mail communication to a nutritionist (KD) that Patient 6 had not been "making the progress I anticipated."

95. Since the FDA does not regulate LDA it must be compounded individually. The composition must be specified for each patient use.

96. The Respondent failed to document a specific prescription for Patient 6 for the LDA.

97. The Respondent failed to include signed informed consent forms in Patient 6's record indicating that Patient 6's parents were aware of the risks of the alternative therapies he was prescribing.

98. The Respondent failed to meet appropriate standards for the delivery of quality medical care of Patient 6 in violation of Health Occ. § 14-404(a)(22).

Patient 7

99. Patient 7, a male, began seeing the Respondent at seven months of age on January 30, 2012, for parental concerns regarding "autistic behavior." The Respondent saw Patient 7 on four occasions.

100. The Respondent conducted a physical examination during the initial visit, but failed to conduct any examinations, measurements or vital signs on any of the subsequent three visits through August 28, 2012.

101. Initially, the Respondent recommended maternal dietary changes as Patient 7 was being breast fed. At one year of age he was well and developmentally normal although sensitive to many foods. He had a history of three episodes of otitis media (ear infection).

102. The Respondent was in communication with KO, who made dietary recommendations for Patient 7.

103. On April 10, 2012, Patient 7's mother informed the Respondent by e-mail that she thought Patient 7 had experienced seizure activity the day before. The Respondent recommended the name of a pediatric neurologist, Dr. R.

104. On April 17, 2012, Patient 7 was evaluated by Dr. R, who diagnosed Patient 7 as "likely" having celiac disease (gluten intolerance) and rule/out generalized epilepsy. He further documented that Patient 7 had no evidence of ASD and that essentially his development for a 10 month old was normal. He recommended that Patient 7 not receive any treatment recommended by KD, who had "never met" Patient 7, and was not a physician or a nurse practitioner.

105. By e-mail dated August 22, 2012, Patient ?'s mother inquired about LDA for Patient 7 and/or her older child. 106. Shortly thereafter, the Respondent started Patient 7 on LDA injections.

107. The Respondent failed to document that Patient 7 had any allergies.

108. LDA is not FDA approved nor is it an accepted treatment for allergies.

109. Since the FDA does not regulate LDA it must be compounded individually. The composition must be specified for each patient use.

110. The Respondent failed to document a specific prescription for Patient 7 for the LDA.

111. The Respondent failed to include signed informed consent forms in Patient Ts record indicating that Patient 's parents were aware of the risks of the alternative therapies he was prescribing.

112. The Respondent failed to meet appropriate standards for the delivery of quality medical care of Patient 7 in violation of Health Occ. § 14-404(a)(22).

II. CONCLUSIONS OF LAW

Based on the foregoing Findings of Fact, the Board concludes as a matter of law that the Respondent's actions and inactions constitute violations of Md. Health Occ. Code Ann. § 14-404(a)(22).

III. ORDER

Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby:

ORDERED that the Respondent is REPRIMANDED under § 14-404(a) of the Health Occupations Article; and it is further

ORDERED that the following are permanent conditions:

1. The Respondent shall not administer chelation therapy;

2. The Respondent shall not administer ketoconazole, itraconazole or fluconazole for non-FDA purposes; and it is further

ORDERED that the Respondent is placed on a minimum of TWO (2) YEARS of PROBATION. The Respondent must fully and satisfactorily comply with the following probationary terms and conditions:

a. The Respondent shall ensure that prior to receipt of a proposed treatment modality that is alternative or complementary, defined as not generally accepted in the medical community as standard treatment, the patients or parents/guardians must be clearly informed of the fact. The patients or parents/guardians shall receive appropriate informed consent, and the informed consent shall be documented in the medical record. The informed consent shall include a Board-approved form specific to each alternative 16 treatment modality to be included in the patient's medical record, and that is signed by the Respondent, the patient or parent/guardian and is witnessed. Within ten (10) days of the execution of this Consent Order, the Respondent shall provide the Board or a panel of the Board, through the Probation Unit, with a copy of all current treatment specific informed consent forms for complementary or alternative medical therapies for Board-approval. Prior to initiating any new alternative or complementary therapy, the Respondent shall ensure that the informed consent form is Board-approved;

b. Within TWO (2) years of the execution of this Consent Order, the Respondent shall pay a monetary fine in the total amount of FIVE THOUSAND DOLLARS ($5,000). The payment or payments shall be by certified or bank guaranteed check(s) made payable to the Maryland State Board of Physicians. The check(s) should be mailed to: Maryland State Board of Physicians, P.O. Box 37217, Baltimore, Maryland, 21297;

c. After a period of one year of probation, the Board may in its discretion conduct a chart and/or peer review of the Respondent's practice. An unsatisfactory review may be considered a violation of this Consent Order; and it is further ORDERED a violation of any of the requirements in the preceding paragraphs shall constitute a violation of probation and/or this Consent Order and, the Board, or Board disciplinary panel, in its discretion, after notice and opportunity for a show cause hearing before the Board or Board disciplinary panel, or an evidentiary hearing at the Office of Administrative Hearings, may impose additional sanctions authorized under the Medical Practice Act, including a reprimand, suspension, an additional period of probation, revocation and/or a monetary fine; and it is further

ORDERED that after TWO (2) years from the effective date of this Consent Order, the Respondent may submit a written petition to the Board requesting termination of probation. After consideration of the petition, the probation may be terminated, through an order of the Board or designated Board committee. The Board, or designated Board committee, will grant the termination if the Respondent has fully and satisfactorily complied with all of the probationary terms and conditions and there are no pending complaints related to the charges; and it is further

ORDERED the Respondent is responsible for all costs incurred in fulfilling the terms and conditions of the Consent Order.

ORDERED that this Consent Order shall be a PUBLIC DOCUMENT pursuant to Md. State Gov't Code Ann.§ 10-611 et seq.

CONSENT ORDER

I, Richard E. Layton M.D., acknowledge that I am represented by counsel and have consulted with counsel before entering into this Consent Order. By this Consent and for the sole purpose of resolving the issues raised by the Board, I agree and accept to be bound by the foregoing Consent Order and its conditions.

I acknowledge the validity of this Consent Order as if entered into after the conclusion of a formal evidentiary hearing in which I would have had the right to counsel, to confront witnesses, to give testimony, to call witnesses on my own behalf, and to all other substantive and procedural protections provided by law. I agree to forego my opportunity to challenge these allegations. I acknowledge the legal authority and jurisdiction of the Board to initiate these proceedings and to issue and enforce this Consent Order. I affirm that I am waiving my right to appeal any adverse ruling of the Board that I might have filed after any such hearing.

I sign this Consent Order after having an opportunity to consult with counsel, voluntarily and without reservation, and I fully understand and comprehend the language, meaning and terms of the Consent Order.

Date: October 17, 2013

____________________
Richard E. Layton, M.D.

This page was posted on May 21, 2015.

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