Louisiana State Seal
Department of Health and Hospitals logo
Secretary
Rebekah E. Gee, MD, MPH
Back to LDH
Provider & Plan Resources
Louisiana.gov > LDH > Provider & Plan Resources
  • What is Healthy Louisiana?
  • I am A...
    • Recipient
    • Health Care Provider
    • Health Plan Representative
  • Dental
  • Pharmacy
  • Behavioral Health
  • Informational Bulletins
  • Reporting and Accountability

Facility Notification System Forms

 Training

  • Click here to learn how to manage information for your personal account and your provider's profile
  • Click here to learn how to submit new forms, finish incomplete forms and view previously submitted forms
  • Provider Portal User Guide

Blank Forms - 1-HPE

1-HPE 

Blank Forms - 142BH

142BH

Blank Forms - 148

PLI

Admission

Discharge

Status Change

Death

Transfer

Blank Forms - 148W

Linkage

Discharge

Status Change

Blank Forms - Newborn Request

Newborn Request

TPL

Feedback
LDH Facebook LDH Blog LDH Twitter
Mailing Address: Louisiana Department of Health | P. O. Box 629 | Baton Rouge, LA 70821-0629
Physical Address: 628 N. 4th Street | Baton Rouge, LA 70802 | PHONE: 225-342-9500 | FAX: 225-342-5568
Medicaid Customer Service 1-888-342-6207 | Healthy Louisiana 1-855-229-6848
Site by Covalent Logic