La. Admin. Code tit. 46 § LXIII-2117
(Name of Psychologist or Group)
(Address)
(Telephone Number)
________________
DISCLOSURE OF FINANCIAL INTEREST
As Required by R.S. 37:1744; R.S. 37:1745, and
LAC 46:LXIII.2101-2115
TO: ________________ Date: ________________
(Name of Patient to be Referred)
________________
(Patient Address)
________________
Louisiana law requires psychologists 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 psychologist 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 ACKNOWLEDGMENT
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, § LXIII-2117