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Schedule Today!

amandae.slpc@gmail.com
(225) 774-0733

Home
Services
Providers
Patient Resources
News and Education
- COVID-19 Updates
- Blog
Careers

Schedule Today!

Please See Paperwork Below

You may print and complete your paperwork prior to your appointment and bring it with you or,
you may complete your paperwork in our office prior to your scheduled appointment time.

If you need assistance completing your paperwork, please ask any member of our team – we are happy to help!

You may print and complete your paperwork prior to your appointment and bring it with you.
Or, you may complete your paperwork in our office, likely increasing your wait time.

If you need assistance with these, please let any member of our team know – we’re happy to help!

NEW PATIENT PACKET

Packet

AUTHORIZATION TO RELEASE RECORDS

Form

Louisiana Authorization to Release or Obtain Health Information | HIPAA

Name *

Request Date *

Mailing Address *

Date of Birth

City/State/Zip *

Medicaid # or Social Security # *

I authorize

Name *

Mailing Address *

City/State/Zip *

Relationship *

Telephone Number *

TO RELEASE Information TO ORTO OBTAIN Information FROM(Place an “X” in the box that indicates if the information is being released OR requested.)

Name *

Mailing Address *

City/State/Zip *

Relationship *

Telephone Number *

The Purpose of this Authorization is indicated in the box(es) below. (Place an “X” in the box(es) that apply.)Further Medical CarePersonalLegal Investigation or ActionChanging PhysiciansResearch related treatmentCreating health information for disclosure to a third party.Other

Other(Specify)

I authorize the release of the following protected health information. (Place an “X”in the box(es) that apply to the information you want released or you want to obtain.)Entire RecordMedical History, Examination, ReportsSurgical ReportsTreatment or TestsPrescriptionsImmunizationsHospital Records including ReportsLaboratory ReportsX-ray ReportsMR/DD RecordsOther

Other(Specify)

In compliance with state and/or federal laws which require special permission to release otherwise privileged information, please release the following records. (Place an “X”in the box(es) that apply to the information you want released or you want to obtain.)Alcoholism †Drug Abuse †Mental HealthVocational RehabilitationHIV (AIDS)Sexually Transmitted DiseasesGeneticsPsychotherapy NotesOther

Other(Specify)

This authorization shall expire on

(date or event)

and is needed for the period

beginning

and

ending

I understand that if I do not specify an expiration date, this authorization will expire six (6) months from the date on which it was signed. I acknowledge that I have read this form.

Date

For LDH Use When Requesting RecordsI am authorized to receive this disclosure. Documentation on the above Personal Representative has been obtained. I consent and accept to use a typed name as my legal and binding signature. I agree I have the ability to check the "Cancel" box at any time should I wish not to proceed.

Name/Signature *

Date

† Provider shall be given a copy of the signed document that acknowledges their receipt of Federal Rule 42 CFR § 2.32 - Prohibition on redisclosure.

Consent *

Yes, I the signer accept that the information in this form is accurate and I adhere to the conditions set by this form.

Cancel

HIPAA 402P

Contact: (225) 774-0733

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