LAC 46: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)