Brian Foster
 
 
 Brian Foster DOB: Apr 03, 1997 (39 yo M) Acc No. 45128 Doc Name: Mar 26, 2019 Inj 
 LA Health Solutions 
 PATIENT CONSENT FOR 
 VIDEOTAPING/PHOTOGRAPHING PROCEDURE 
 Brian Foster 
 Apr 03, 1997, 45128, male 
 I 
 ( Patient') hereby consent to and 
 authorize LA HEALTH SOLUTIONS, L.L.C. ( LA Health Solutions) to videotape or 
 photograph the above-noted Procedure and retain a copy of said videotape/photograph (s) 
 in my patient record It is my understanding that such videotape/photograph (s) will be 
 made a part of my patient record and shall be subject to the Privacy and Security 
 regulations contained in the Health Insurance Portability and Accountability Act of 1996 
 ( HIPAA '). 
 Except to the extent action has already been taken in reliance on this consent, this 
 consent may be revoked at any time by submitting a written notice to Louisiana Health 
 Solutions, L.L.C., 56634 Bosworth Street, Slidell, Louisiana 70458. 
 Date: 01-21-2023 
 PATIENT Signature 
 Relative signature 
 Name: 
 Date: 
 S 
 LAHS employee signature 
 Date: 
 Nov 08, 2018 
 Brian Foster DOB: Apr 03, 1997 (39 yo M) Acc No. 45128 Doc Name: Mar 26, 2019 Inj 
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