Disclaimer:
This form was promulgated by industry representatives in cooperation with provider
representatives to amend and reenact R. S. 22:11 in accordance with Act 671 of the
2004 legislative session and Act 374 of the 2005 legislative session.
The form and the contents therein are not the product of the Louisiana Department
of Insurance. This form is being posted on our website as a courtesy to industry
and providers.
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