La. Admin. Code tit. 46 § XLVII-3619

Current through Register Vol. 50, No. 6, June 20, 2024

Section XLVII-3619 - Appendix- Financial Interest Disclosure Form

Appendix

Referring Nurse_________________________ Phone _________________

Employer_____________________________________________________

Address______________________________________________________

DISCLOSURE OF

FINANCIAL INTEREST

AS REQUIRED BY R.S. 37:1744 AND

LAC 46:XLVII.3603-3607

To:__________________________ Date:__________________________

(Name of Patient to Be Referred)

____________________________________

(Patient Address)

Louisiana law requires registered nurses 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 registered nurse has a 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 [I am] [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. I acknowledge that I have been advised by the above identified nurse of the nurse's financial or ownership interest in the facility or entity to which I have been referred and further, that the nurse has advised me that I am free to choose another facility or entity to provide the service, drug, device or equipment recommended.

_____________________________________________________________

(Signature of Patient or Patient's Representative)

La. Admin. Code tit. 46, § XLVII-3619

Promulgated by the Department of Health and Hospitals, Board of Nursing, LR 21:271 (March 1995), amended LR 24:1293 (July 1998).

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1745 and R.S. 37:918