Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 1 - General
Chapter 5 - Disclosure of Confidential Information
Section I-513 - Disclosure Forms
Current through Register Vol. 50, No. 9, September 20, 2024
A. Patient /Client Form
DISCLOSURE RECORD
FOR
(Name of Patient)
|
FOR INITIATING OFFICE USE ONLY (For Optional Use Only) Care record name: ____________________________________ Care record number: ____________________________________ Social Security #: ____________________________________ Return to: ____________________________________ |
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
|
FOR INITIATING OFFICE USE ONLY (For Optional Use Only) Care record name: ____________________________________ Care record number: ____________________________________ Social Security #: ____________________________________ Return to: ____________________________________ |
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
|
FOR INITIATING OFFICE USE ONLY (For Optional Use Only) Care record name: ____________________________________ Care record number: ____________________________________ Social Security #: ____________________________________ Return to: ____________________________________ |
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
AUTHORITY NOTE: Promulgated in accordance with R.S. 44:7.
