La. Admin. Code tit. 46 § XLV-4219
[Name of Physician/Group]
[Address]
[Telephone Number]
_________________
DISCLOSURE OF
FINANCIAL INTEREST
As Required by R.S. 37:1744 and
LAC 46:XLV.4211-4215
___________________
TO: ______________________________________________________
DATE: ____________
(Name of Patient to Be Referred)
_____________________________
(Patient Address)
_____________________________
Louisiana law requires physicians and other health care providers to make certain disclosures to a patient when they refer a patient to another health care provider or facility in which the physician has a significant financial interest. [I am/we are] referring you, or the named patient for whom you are legal representative, to:
________________________________________
(Name and Address of Provider to Whom Patient is Referred)
to obtain the following health care services, products, or items:
_________________________________________
(Purpose of the Referral)
[I/we] have a financial interest in the health care provider to whom we are referring you, the nature and extent of which are as follows:
____________________________________________
____________________________________________
____________________________________________
PATIENT ACKNOWLEDGEMENT
I, the above-named patient, or legal representative of such patient, hereby acknowledge receipt, on the date indicated and prior to the described referral, of a copy of the foregoing Disclosure of Financial Interest.
_______________________________________
(Signature of Patient or Patient's Representative)
La. Admin. Code tit. 46, § XLV-4219