LAC 48:I.513. Disclosure Forms

A. Patient /Client Form DISCLOSURE RECORD FOR (Name of Patient) DDHR Form 1 Issued 12/80 DEPARTMENT OF HEALTH AND HUMAN RESOURCES CONSENT TO DISCLOSURE OF CASE INFORMATION WAIVER OF CONFIEDNTIALITY PATIENT/CLIENT FORM I, __________________, understand that the information contained in my record is confidential. However, I give my consent for ____________________ to release to _____________________ the following specific information: __________________________________________________________________________________________________________________________ The above-listed information is to be disclosed for the specific purposes of _______________________. This consent is subject to written revocation at any time except to the extent that action has already been taken upon this consent. This consent will automatically expire __________________. Witness Signature of Patient/Client Witness Date B. Authorized Representative Form DDHR Form 2 Issued 12/80 DEPARTMENT OF HEALTH AND HUMAN RESOURCES CONSENT TO DISCLOSURE OF CASE INFORMATION WAIVER OF CONFIEDNTIALITY FORM FOR AUTHORIZED REPRESENTATIVE I, _____________________________, am the _______________ of ____________________________________, a ______________________. I understand that the information constined in ____________________'s record is confidential. However, I give my consent for _______________________ to release to _____________________ thr following information : __________________________________________________________________________________________________________________________ The above-listed information is to be disclosed for the specific purposes of _______________________. This consent is subject to written revocation at any time except to the extent that action has already been taken upon this consent. This consent will automatically expire __________________. Date Signature of Authorized Representative Witness Witness Signature of Patient/ Client, if a minor (if applicable see instruction) C. Primary Source Form DDHR Form 3 Issued 12/80 DEPARTMENT OF HEALTH AND HUMAN RESOURCES CONSENT TO DISCLOSURE OF CASE INFORMATION WAIVER OF CONFIEDNTIALITY PRIMARY SOURCE FORM _________________________________________ hereby authorizes ____________________ to release to ________________________ the following specific information: __________________________________________________________________________________________________________________________ Witness Authorized Signature of Health Care Provider Witness Date