Martha Curry
 
 
 Martha Curry DOB: 28/11/93 (53 yo M) Acc No. 56005 Doc Name: 08/08/18 Financial Disclosure 
 Disclosure of Financial Interest Form 
 LA HEALTH SOLUTIONS, LLC and LYLE J. SCHWEEN, BS DC 
 DISCLOSURE OF 
 FINANCIAL INTEREST 
 as required by R.S. 37:1744 and LAC 46:XXVII.911, et seq 
 Date: 21/06/17 
 Patient Name: Martha Curry 
 Louisiana law requires LA HEALTH SOLUTIONS, LLC and LYLE J. SCHWEEN, BS DC, and other health care providers 
 to make certain disclosures to a patient when they refer a patient to another health care provider or facility in which the 
 health care provider has a significant financial interest. One of the health care providers listed above may refer you, or the 
 named patient for whom you are legal representative, to:  
 PATIENT ACKNOWLEDGEMENT 
 I, the above-named patient, or legal representative of such patient, hereby acknowledge receipt, on the date 
 indicated and prior to the described referral, of a copy of the foregoing Disclosure of Financial Interest. 
 (Signature of Patient 
 or Patient's Representative) 
 Print Name: Justin Ganloald 
 Date: 30/03/19 
 Martha Curry DOB: 28/11/93 (53 yo M) Acc No. 56005 Doc Name: 08/08/18 Financial Disclosure 
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