Louisiana Patient's Compensation Fund

Authorization for Release of Confidential Information

Print note: Data entered into this HTML form is not saved after the page is closed.

I am hereby authorizing and consenting to the disclosure of information by the Louisiana Patient's Compensation Fund relative to medical malpractice records and enrollment records as a participant in the Fund, which pertains to my professional qualifications, professional liability insurance coverage and malpractice claims history to the entity named below.

Information to release

Claims history for credentialing purposes. Due to legislation that became effective 8/15/04, this office will no longer be able to provide a list of all claims filed against health care providers. Act 306 of the 2004 regular session prohibits reporting of panel requests to certain entities. Only suits can be reported. Since this agency is not a named defendant in suits, we do not receive notice and therefore we are not able to provide this information. We will only be able to provide information on claims in which a payment has been made on behalf of the provider by this agency. See 2004 Act 306 for further details.

Full claims history. Please note that by selecting this option you are waiving protection of 2004 Act 306 and all panels will be included on the list.

Receiving Entity

Named Entity

Contact Person

Address Line 1

Address Line 2

City, State, Zip Code

Phone/Fax

Health Care Provider

Name

Address Line 1

Address Line 2

City, State, Zip Code

Phone Number

Signature of Health Care Provider

Date