Request for Consideration of a Medicaid Policy Change

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E-Mail Address

Please fill out and submit the form below to request Louisiana Medicaid consider a policy change.

Please attach supporting publications, bibliography, or other documents to a completed request for consideration form for a new eligibility group/population to be considered for coverage by Louisiana Medicaid.

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

Contact Information

Date Submitted

Name of Requestor

(First)

(Last)

Organization (if applicable)

Role of Requestor

Address

City, State

Zip Code

Phone

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