Request for Consideration of Meeting with OBH Assistant Secretary

E-Mail Address

Providers and vendors may request a meeting with OBH Assistant Secretary. Please fill out and submit a request for consideration form in order to make the request.

Please email supporting supporting publications, bibliography, or other documents to the following (OBHRequest@la.gov)

Relevant research studies submitted should be free of industry bias and non-industry supported.

Contact Information

Name of Requestor

(First)

(Last)

Organization (if applicable)

Address

City, State

Zip Code

Phone

E-mail

Procedure, Treatment, or Service Information

What is the name of the procedure, treatment, or service that you would like to discuss with the OBH Assistant Secretary?

Answer

Provide a brief description of the treatment, procedure, or service that you would like to discuss with the OBH Assistant Secretary (please include billing codes, if known).

Provide description here

Provide a brief description of current alternative treatments, procedures, or services (please include billing codes, if known).

Provide description here

What are the patient populations covered by this request?

List conditions, age, gender, ethnicity, etc.

What are the desired and/or expected outcomes? (e.g., improved survival, decreased need for hospitalization)

List desired outcomes here

In what settings would this be used? (e.g., inpatient/outpatient)

List here

What types of providers would use this intervention? (e.g., type of physician, therapists, advanced practice nurses)

List provider type(s) here

Is this approved by the FDA?

Yes

Unknown

If yes, for what indications has it been FDA-approved?

Is this treatment, procedure, or device considered experimental, investigational, or cosmetic?

Yes

Unknown

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