Medicaid Provider Forms
If you don't see the form you are looking for, see the other Medicaid provider forms at the Medicaid Provider site.
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Provider Request for Eligibilty Status Use this form to request Eligibility Status for one or multiple Medicaid recipients. Submit this form to Louisiana Medicaid by Fax to 1-866-861-6016.If no response is received after 14 days, or to report concerns, please contact Julie Mayeaux: Ph: 225/922-0147 Email: julie.mayeaux@la.gov. |
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Provider Request for Spend-Down Medically Needy Notice (BHSF Form 110MNP) Use this form to request form 110-MNP for recipients with coverage in the Spend-Down Medically Needy Program. List only services that occurred on the spend-down date (beginning date of Medicaid coverage). Submit only one form per fax to 1-866-861-6016. If no response is received within 14 days, or to report concerns, please contact Charlotte Ducote: Ph: 318/487-5348 Email: charlotte.ducote@la.gov. |
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Notification of Admission, Status, Change, or Discharge for Facility Care (Form 148) Complete this form to notify Medicaid of admission, status change, or discharge for facility care. |
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PACE Notification of Enrollment, Status Change or Disenrollment (Form 148-P) Complete this form to notify Medicaid of admission, status change, or discharge for PACE services. |
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Notification of Admission, Status Change, or Decertification/Discharge for HCBS Waiver (Form 148-W) Complete this form to notify Medicaid of admission, status change, or discharge for Home and Community Based Waiver Services. |