LAC 46:XLVII.3619. Appendix―Financial Interest Disclosure Form

Referring Nurse_________________________ Phone _________________ Employer_____________________________________________________ Address______________________________________________________ DISCLOSURE OF FINANCIAL INTEREST AS REQUIRED BY R.S. 37:1744 AND LAC 46:XLVII.3603-3607 To:__________________________ Date:__________________________ (Name of Patient to Be Referred) ____________________________________ (Patient Address) Louisiana law requires registered nurses 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 registered nurse has a 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 [I am] [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. I acknowledge that I have been advised by the above identified nurse of the nurse's financial or ownership interest in the facility or entity to which I have been referred and further, that the nurse has advised me that I am free to choose another facility or entity to provide the service, drug, device or equipment recommended. _____________________________________________________________ (Signature of Patient or Patient's Representative)