La. Admin. Code tit. 46 § LIII-3119
[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)
La. Admin. Code tit. 46, § LIII-3119