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Dr. Courtney N. Phillips
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Aging and Adult Services
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OAAS Forms

August 26, 2021

Forms for various programs and services offered through the Office of Aging and Adult Services:

  • LT-PCS Rights and Responsibilities Form
  • Statement of Medical Status & Instructions
  • MFP/My Place LA Form
  • LTPCS Service Log and Instructions
  • CCW Service Log and Instructions
  • Request for Payment Override Form and Instructions
  • Confidentiality Consent for Shared PAS and LT-PCS
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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
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