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 Joy Biro: Ph: 318/253-0539 Email: joy.biro@la.gov

 

 Provider Request for Spend-Down Medically Needy Notice(BHSF Form 110MNP)

Use this form to request form 110-MNP. 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 Joy Biro: Ph: 318/253-0539 Email: joy.biro@la.gov.

     

 

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.

     

 

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.

     

 

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.