Louisiana Department of Health Forms

This form is used for registering out-of-state soft drinks in Louisiana.

This form is used for applying for a new product registration in the state of Louisiana.

This document is used for reporting complaints to the Louisiana EMS Certification Commission (EMSCC). It provides a form for individuals to report any issues or concerns related to EMS services in the state of Louisiana.

This document allows individuals in Louisiana to request non-opioid pain management options in medical treatment.

This form is used for providers in Louisiana to request to be added to the Medicaid Freedom of Choice List for Waiver Services.

This form is used for referring patients in nursing facilities for MDS 3.0 Section Q assessments in the state of Louisiana.

This document provides instructions for completing the Form GNOCHC-1 Excel Encounter Data, which is used in Louisiana. The form is used to collect encounter data for the Greater New Orleans Community Health Connection program.

This document provides instructions for reporting infrastructure investment expenditures in Louisiana for Form GNOCHC-2. It outlines the process and requirements for completing the form.

This Form is used for submitting the Community Care Coordination Quarterly Report in the state of Louisiana. It provides instructions on how to fill out and submit the report accurately and on time.

This document is used for certifying electronically-submitted Medicaid claims in the state of Louisiana. It ensures that healthcare providers meet specific standards for submitting claims using electronic data interchange (EDI) systems.

This type of document is used for obtaining certification for electronically-submitted Medicaid claims for the Healthy Louisiana Prepaid Plan in the state of Louisiana.

This document is used for notifying recipients of the Louisiana Medicaid Hospice Program about their options for election, revocation, discharge, or transfer.

This document is used for certifying terminal illness for individuals seeking hospice care under the Louisiana Medicaid Program in Louisiana.

This form is used for submitting a request for Medicaid subrogation in the state of Louisiana.

This document is a request form for Louisiana residents who qualify for Medicaid through the medically needy program and need to meet a spend-down requirement. It is used to notify the Medicaid provider about the need to spend down income or resources to qualify for medical coverage.

This document is for providers in Louisiana who need information on how to request a Spend-Down Medically Needy Notice. It provides instructions on the process and requirements for this request.

This document is used to request the deduction of incurred medical expenses under the Medicaid program in Louisiana.

This form is used for authorizing the release or obtaining of health information in Louisiana. It ensures compliance with HIPAA regulations for the protection of personal health information.

This Form is used to request a Medicaid ID number for a newborn in the Medicaid Program in Louisiana.

This document updates the insurance information of Medicaid recipients in Louisiana.

This form is used for submitting institutional healthcare claims to Medicare Advantage plans in Louisiana.

This form is used for submitting professional crossover claims to Medicare Advantage plans in Louisiana.

This form is used for extending a physician outpatient visit in Louisiana through BHSF.

This form is used to refer pregnant individuals to the Medicaid program in Louisiana for dental services related to pregnancy.

This form is used for keeping a record of non-emergency medical transportation in Louisiana.

This document is designed for the assessment of personal care needs according to the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) service in Louisiana. It gathers critical information about an individual's social circumstances, physical health, and personal care requirements.

This document is used for conducting a survey of FQHC (Federally Qualified Health Center) services facilities in Louisiana.

This form is used for requesting Medicaid EPSDT Personal Care Services in Louisiana.