LAC 46:LIII.3119. Disclosure of Financial Interest

[Name of Pharmacist/Group] [Address] [Telephone Number] DISCLOSURE OF FINANCIAL INTEREST As Required by R.S. 37:1744 and LAC 46:LIII.613-615 TO:_________________ DATE:____________________ _________________________________ (Name of Patient to Be Referred) _________________________________ (Patient Address) Louisiana law requires pharmacists 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 pharmacist 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 ACKNOWLEDGEMENT 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)