Louisiana Department of Health Forms

This form is used for the Women, Infants, and Children (WIC) Special Supplemental Nutrition Program in Louisiana.

This Form is used for reporting lost or missing receipts in the state of Louisiana.

This document is used to express disagreement when access to health information has been denied in Louisiana. It is for situations concerning the Health Insurance Portability and Accountability Act (HIPAA).

This form is used for tracking the disclosures made under HIPAA (Health Insurance Portability and Accountability Act) in Louisiana. The form helps to ensure the privacy and security of patients' health information.

This form is used for submitting a request to restrict the use and disclosure of your protected health information in Louisiana.

This form is used for accepting a request for a restriction in the state of Louisiana.

This document is used for submitting a request to access records in the state of Louisiana.

This Form is used for responding to a statement of disagreement regarding access to records in the state of Louisiana.

This form is used for acknowledging receipt of NPP (Notice of Privacy Practices) in Louisiana, in accordance with HIPAA regulations.

This form is used for individuals in Louisiana who have been denied access to records and wish to file a complaint or appeal.

This form is used in Louisiana to request a 30-day extension to respond to an amendment request.

This form is used for requesting an amendment or correction to a health record in the state of Louisiana.

This form is used for reporting disagreement with the denial of a request to amend or correct health information under HIPAA regulations in the state of Louisiana.

This form is used for revoking authorization in the state of Louisiana.

This form is used for requesting an accounting of disclosures made by a healthcare provider in Louisiana.

This form is used for applying for health coverage in Louisiana through the BHSF program.

This document establishes the regulations for retail food establishments in Louisiana to ensure sanitary conditions and public health.

This Form is used for Level 1 Pre-admission Screening and Resident Review in the state of Louisiana. It is a document that helps evaluate the needs of individuals who are seeking admission to long-term care facilities.

This form is used for requesting continued stay in Louisiana.

This form is used for reporting critical incidents related to Home and Community Based Services (Waiver Services) in Louisiana.

This Form is used for obtaining an emergency certificate for psychologists in Louisiana. It allows qualified psychologists to provide immediate mental health care during emergencies.

This form is used for physicians in Louisiana to certify emergency medical treatment for a patient.

This Form is used for issuing an emergency certificate by the coroner in Louisiana. It allows the coroner to certify the cause of death in emergency situations.

This form is used for acknowledging the notification of rights in the state of Louisiana. It is used to confirm that an individual understands their rights as provided by the law.

This form is used for transferring ownership of a vehicle in the state of Louisiana.

This form is used for formal voluntary admission at a healthcare facility in Louisiana. It is a legal document that allows individuals to seek medical treatment and services voluntarily.

This form is used for physicians in Louisiana to report information to the court. It is used for legal purposes regarding medical matters.

This form is used for non-contested admissions in Louisiana.

This form is used for notifying the family of a person's admission to a hospital on an emergency certificate in Louisiana.

This form is used for requesting protective custody in the state of Louisiana. It is used to document the request and provide necessary information for evaluation and investigation.

This Form is used for requesting the formal voluntary admission of an individual in the state of Louisiana.

This form is used for obtaining a physician's certificate for a minor in the state of Louisiana. It is required for various purposes such as school enrollment or participation in sports activities.

This form is used for placing someone under protective custody in the state of Louisiana. It allows authorities to remove an individual from a potentially dangerous situation for their safety.

This document is used for determining the annual permit fee in the state of Louisiana. It provides a worksheet for assessing the fee based on specific criteria.

This document verifies the reciprocity of Emergency Medical Services in Louisiana. It ensures that EMS providers from other states meet the necessary requirements and can practice in Louisiana.