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402P Form (Report) (Louisiana)

The 402P form must be completed for each non-covered requester (parents, guardians, third-party requesters) on behalf of a parent or guardian. This collection form, data, and signature (when required) are automated and electronically stored to avoid paper record handling. This is used by LINKS public health units.

In order for this form to open, the user must be assigned to a Facility or a Facility and patient must be selected. The Launch 402P Form button on the Patient Demographics page can also be used to access this form.

Run the Report

To run this report, first select a Facility and patient, if necessary, then click the Reports > State Reports > Patient Specific > 402P Form link. The 402P Form page opens.  Enter the criteria and click one of the buttons:

The available report fields are as follows:

Field Description

Patient Name

This field is automatically populated with the patient's name, but can be updated if necessary.

Mailing Address

This field is automatically populated with the patient's address, but can be updated if necessary.

City/State/Zip

This field is automatically populated with the patient's city, state, and zip code, if recorded in the patient record.

Request Date

The current date is automatically entered.

SSN

This field displays depending on the user's access level and application settings.

Date of Birth

This field is automatically populated with the patient's birthdate, but can be updated if necessary.

The following party: Name / Address / City / State / Zip Code / Phone

The Facility's information is automatically populated into these fields.

Is authorized to release information to: First Name / Middle Name / Last Name / Address / City / State / Zip Code / Phone / Relationship

If a person or location is already recorded, select it from the drop-down list. Otherwise, enter the information in the appropriate fields.

Purpose of Authorization

Select the purpose(s) for the authorization. Examples: Further Medical Care, Changing Physicians, Other. If Other is selected, enter the purpose.

The image below shows the first page that appears after clicking the Reports > State Reports > Patient Specific > 402P Form link:

Example 402P Form page for Louisiana

Example Report

The following image shows an example 402P form for a sample patient (obtained by clicking on the authorization form release date link. The authorization form was created when the Create New Form button was clicked):

Example 402P Form for Louisiana

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