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. 6, June 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.