La. Admin. Code tit. 46 § LXIII-2117

Current through Register Vol. 50, No. 9, September 20, 2024
Section LXIII-2117 - Disclosure of Financial Interest

(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

Promulgated by the Department of Health and Hospitals, Board of Examiners of Psychologists, LR 21:1335 (December 1995).
AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1744 and R.S. 37:1745.