LAC 46:LIII.3115. Form of Disclosure

A. Required Contents. The disclosure required by §3113 of this Subchapter shall be made in writing, shall be furnished to the patient, or the patient's authorized representative, prior to or at the time of making the referral, and shall include: 1. the pharmacist's or pharmacy's name, address, and telephone number; 2. the name and address of the health care provider to whom the patient is being referred by the pharmacist or pharmacy; 3. the nature of the items or services which the patient is to receive from the health care provider to which the patient is being referred; and 4. the existence and nature of the pharmacist's or pharmacy's financial interest in the health care provider to which the patient is being referred. B. Permissible Contents. The form of disclosure required by §3113 of this Subchapter may include a signed acknowledgment by the patient or the patient's authorized representative that the required disclosure has been given. C. Approved Form. Notice to a patient given substantially in the form of Disclosure of Financial Interest prescribed in §3119 of this Subchapter shall be presumptively deemed to satisfy the disclosure requirements of this Subchapter.