Louisiana Medicaid Application Center Resource Library

 

CONTACT INFORMATION

Josie McElroy

ApplicationCenter.Service@la.gov

Fax: (225) 376-4736   

 

 

MAC Partner Division of Administration Registration 

 

News and Updates

App Center Online Training  

 

Application Center Documents 

Please limit use of the printable application to instances when use of the Self Service Portal is unavailable or impractical.

Application Center Evaluation  
Application Center Handbook

 

General Application  
General Application - Additional Persons  
General Application - Employer Coverage Tool  
General Application - Appendix D - Personal Assets  
General Application - Spanish  
General Application - Vietnamese  
AC-5 (Log of Referrals) Instructions

AC-7 (RightFAX Cover and Transmittal Log)    Updated 12.17.18

Instructions

AC-8 (Inspection / Monitoring Report)

Instructions

AC-8a (Monitoring Corrective Action Results)

Instructions

AC Signage Template

 

AR (Consent for Authorized Representation)

Instructions

Clearance (Statement of Applicant)

Instructions

Health Plan Non-Timely Filing Procedures  
Healthy LA Comparison Chart - Printout  
Healthy LA Comparison Chart - Web Viewing  
HIPAA 202L (Authorization to Release Health Information)  

HIPAA 402P (Authorization to Release or Obtain Health Information)

Instructions

Ins-LR (Request for Life Insurance Policy Information)

Instructions

MS (Social Information Interview)

Instructions

MS/C (Child's Medical & Social Interview)

Instructions

Resources (Request for Resources & Interest Income Information)

Instructions

Verification (Application Verification Request Form)

Instructions

Voter Registration Application (LR-1 & 1M)

 

Voter Registration Declaration (English)

 

Voter Registration Declaration (Spanish)

 
Voter Registration Declaration (Vietnamese)  


Voter Registration Poster (English)

 

Voter Registration Poster (Spanish)

 

Voter Registration Poster (Vietnamese)

 

Wages (Personal Wage Record)

 Instructions
WIC 38 Flyer