La. Admin. Code tit. 48 § I-513

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-513 - Disclosure Forms

A. Patient /Client Form

DISCLOSURE RECORD

FOR

(Name of Patient)

FOR INITIATING OFFICE USE ONLY (For Optional Use Only) Care record name: ____________________________________ Care record number: ____________________________________ Social Security #: ____________________________________ Return to: ____________________________________

DDHR Form 1

Issued 12/80

DEPARTMENT OF HEALTH AND HUMAN RESOURCES

CONSENT TO DISCLOSURE OF CASE INFORMATION

WAIVER OF CONFIEDNTIALITY

PATIENT/CLIENT FORM

I, __________________, understand that the information contained in my record is confidential. However, I give my consent for ____________________ to release to _____________________ the following specific information:

__________________________________________________________________________________________________________________________

The above-listed information is to be disclosed for the specific purposes of _______________________. This consent is subject to written revocation at any time except to the extent that action has already been taken upon this consent. This consent will automatically expire __________________.

______________ _______________

Witness Signature of Patient/Client

________________ _____________

Witness Date

B. Authorized Representative Form

FOR INITIATING OFFICE USE ONLY (For Optional Use Only) Care record name: ____________________________________ Care record number: ____________________________________ Social Security #: ____________________________________ Return to: ____________________________________

DDHR Form 2

Issued 12/80

DEPARTMENT OF HEALTH AND HUMAN RESOURCES

CONSENT TO DISCLOSURE OF CASE INFORMATION

WAIVER OF CONFIEDNTIALITY

FORM FOR AUTHORIZED REPRESENTATIVE

I, _____________________________, am the _______________ of ____________________________________, a ______________________. I understand that the information constined in ____________________'s record is confidential. However, I give my consent for _______________________ to release to _____________________ thr following information :

__________________________________________________________________________________________________________________________

The above-listed information is to be disclosed for the specific purposes of _______________________. This consent is subject to written revocation at any time except to the extent that action has already been taken upon this consent. This consent will automatically expire __________________.

_______________ _______________

Date Signature of Authorized Representative

________________

Witness

_______________ _____________

Witness Signature of Patient/ Client,

if a minor

(if applicable see instruction)

C. Primary Source Form

FOR INITIATING OFFICE USE ONLY (For Optional Use Only) Care record name: ____________________________________ Care record number: ____________________________________ Social Security #: ____________________________________ Return to: ____________________________________

DDHR Form 3

Issued 12/80

DEPARTMENT OF HEALTH AND HUMAN RESOURCES

CONSENT TO DISCLOSURE OF CASE INFORMATION

WAIVER OF CONFIEDNTIALITY

PRIMARY SOURCE FORM

_________________________________________ hereby authorizes ____________________ to release to ________________________ the following specific information:

__________________________________________________

__________________________________________________

_____________ ___________________

Witness Authorized Signature of Health Care Provider

____________ ________________

Witness Date

La. Admin. Code tit. 48, § I-513

Promulgated by the Department of Health and Human Resources, Office of the Secretary, LR 13:246 (April 1987).

AUTHORITY NOTE: Promulgated in accordance with R.S. 44:7.