Louisiana Authorization To Release Or Obtain Health InformationLouisiana Authorization To Release Or Obtain Health Information
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Louisiana Department of Health and Hospitals
Authorization to Release or Obtain Health Information
For Eligibility in Program Enrollment
(including paper, oral and electronic information)
Name:

Request Date:

Mailing Address:

Date of Birth:

City/State/Zip:

Medicaid ID# or Social Security #:

I authorize:
Name: _____________________________________________________________________________________
Mailing Address: ____________________________________________________________________________
City, State, Zip Code: ___________________________________________

Phone #:___________________

r To Release Information TO
OR
r To 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 Code: _______________________________________________