LAC 46:XLV.4219. Appendix―Disclosure of Financial Interest Form

[Name of Physician/Group] [Address] [Telephone Number] _________________ DISCLOSURE OF FINANCIAL INTEREST As Required by R.S. 37:1744 and LAC 46:XLV.4211-4215 ___________________ TO: DATE: ____________ (Name of Patient to Be Referred) (Patient Address) _____________________________ Louisiana law requires physicians 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 physician 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)