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Louisiana Department of Health & Hospitals | Kathy Kliebert, Secretary

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Statewide Initiatives



211 - Get Connected. Get Answers.

 

Provider Forms

If you don't see the form you are looking for, see the other Medicaid provider forms at the Medicaid Provider site.

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Provider Request for Eligibilty Status

Use this form to request Eligibility Status for one or multiple Medicaid recipients. Submit this form to Louisiana Medicaid by Fax to 1-877-523-2987.

 

 Provider Request for Spend-Down Medically Needy Notice

Use this form to request Spend-Down Medically Needy Notices (BHSF Form 110-MNP) for one or multiple Medicaid recipients. Submit this form to Louisiana Medicaid by Fax to 1-877-523-2987. Questions about ths form should be directed to
Kathryn Honeycutt Ph# 225-342-0411.

     

 

Notification of Admission, Status, Change, or Discharge for Facility Care (Form 148)

Complete this form to notify Medicaid of admission, status change, or discharge for facility care.

     

 

PACE Notification of Enrollment, Status Chage or Disenrollment (Form 148-P)

Complete this form to notify Medicaid of admission, status change, or discharge for PACE services.

     

 

Notification of Admission, Status Change, or Decertification/Discharge for HCBS Waiver (Form 148-W)

Complete this form to notify Medicaid of admission, status change, or discharge for Home and Community Based Waiver Services.