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Free Louisiana Medicaid Freedom of Choice List Form

The Louisiana Medicaid Freedom of Choice List form is a crucial document that allows providers to request inclusion or updates on the Freedom of Choice list for waiver services. This form ensures that individuals can select their preferred providers for various Medicaid services, fostering greater flexibility and choice in their care. If you need to fill out this important form, click the button below to get started.

Open Louisiana Medicaid Freedom of Choice List Editor Here

Free Louisiana Medicaid Freedom of Choice List Form

Structure

The Louisiana Medicaid Freedom of Choice List form is a crucial document for providers participating in the state's Medicaid waiver services. This form allows providers to request their inclusion or update their status on the Freedom of Choice list, which is essential for ensuring that eligible individuals can access necessary services. It requires comprehensive information, including the provider's current and previous names, addresses, contact details, and specific services offered. Providers must indicate the types of services they provide, such as children's choice waivers, personal emergency response systems, or skilled nursing services, along with the relevant regions they serve. Additionally, the form emphasizes the importance of maintaining up-to-date information, as providers are responsible for notifying the Louisiana Department of Health about any changes within ten days. Failure to do so may result in removal from the Freedom of Choice list, which could significantly impact service accessibility for clients. To complete the process, providers must submit the form along with a copy of their current license and Medicaid Provider Enrollment Letter, ensuring compliance with state regulations. Understanding the nuances of this form is vital for providers to maintain their standing and continue offering essential services to those in need.

Sample - Louisiana Medicaid Freedom of Choice List Form

MEDICAID FREEDOM OF CHOICE LIST FOR WAIVER

SERVICES: PROVIDER REQUEST

Please Print/Type ALL Information Requested:

	Current Information		Previous Information

Provider Name:		Former Name:

Provider Address (Include City, State, Zip):		Former Address:

Provider Contact Name:		Former Provider Contact Name:

ProviderPhone- FaxNumber(s)(Includeareacode):		PreviousProviderPhone- FaxNumber(s)(Includeareacode):
Phone:	Fax:	Phone:	Fax:

Provider Toll-Free Phone Number:		Former Provider Toll Free Phone Number:

Provider E-Mail		Former Provider E-Mail

Please place/update/remove the above-named agency on/from the Freedom of Choice list for the provider type(s) checked below.

	03	Children’s Choice (Children’s Choice Waiver)						Region(s):

	06	Professional Services [NOW]
		Checkallapplicableservices:	Psychologist	SocialWorker		Nutritional/Dietary		Region(s):
	11	Shared Living (ROW)						Region(s):

	13	Pre-Vocational						Region(s):
	14	Day Habilitation						Region(s):

	15	Environmental Modifications						Region(s):

	16	Personal Emergency Response System (PERS)						Region(s):

	17	Medical Equipment and Supplies (Assistive Devices)						Region(s):

	31	Psychologist (ROW)						Region(s):
	33	Monitored In Home Caregiving (NOW)						Region(s):

	35	Monitored In Home Caregiving (ROW)						Region(s):

	35	Physical Therapist	CC	ROW	Both CC and ROW			Region(s):
	37	Occupational Therapist	CC	ROW	Both CC and ROW			:
	37	Occupational Therapist	CC	ROW				Region(s)
	39	Speech Therapist	CC	ROW	Both CC and ROW			Region(s):

	41	Registered Dietician (ROW)						Region(s):
	44	Skilled Nursing (NOW)						Region(s):

	44 (4W)	Skilled Nursing (ROW)						Region(s):

	73	Social Worker (ROW)						Region(s):

	82	Personal CareAttendant(PCA):	CC/NOW/SW			ROW		Region(s):

	82 (4W)	If ROW selected above: Check	Community LivingSupports					Region(s):
		If ROW selected above: Check	Companion Care Support
		one:	Companion Care Support
		one:	Both CLS and CCS
			Both CLS and CCS

	83	Center-Based Respite						Region(s):

	84	Substitute Family Care:	NOW			ROW		Region(s):

	85	ROW Adult Day Health Care (ADHC)						Region(s):

	89	Supervised Independent Living (SIL) – (NOW)						Region(s):
	98	Supported Employment						Region(s):

Provider’s Signature and Title:							Date:

ItistheProvider’s Responsibility tonotifytheLouisianaDepartmentofHealth(LDH),WaiverSupportsandServices,regardinganychangesinthe above noted information within ten (10) days of any changes. To keep from being removed from the FOC list, a provider’s license and enrollment must be kept current. This notice will NOT notify DXC Provider Enrollment or Licensing regarding these changes.

The following must be included with all submissions:

Completed 1.) FOC Form, 2.) A copy of your current license, and 3. A copy of your current Medicaid Provider Enrollment Letter(s).

Mail or Fax to:

OCDD/Waiver Supports & Services

628North 4th Street, 2nd Floor Baton Rouge, LA 70802 Fax: (225) 342-8823

Issued July 30, 2020	OCDD-PF-20-005
Replaces all prior issuances

↓ Louisiana Medicaid Freedom of Choice List File

Form Characteristics

Fact Name	Fact Description
Purpose	The Louisiana Medicaid Freedom of Choice List form is used to request the addition, update, or removal of providers from the Freedom of Choice list for waiver services.
Required Information	Providers must print or type all requested information, including current and previous names, addresses, and contact details.
Provider Types	The form covers various provider types, such as Psychologists, Social Workers, and Personal Care Attendants, among others.
Governing Laws	This form operates under Louisiana state laws governing Medicaid waiver services, specifically the Louisiana Department of Health regulations.
Submission Requirements	Providers must include a completed Freedom of Choice form, a current license copy, and a current Medicaid Provider Enrollment Letter with their submission.
Notification Responsibility	It is the provider's responsibility to notify the Louisiana Department of Health of any changes in information within ten days.
Current License	To remain on the Freedom of Choice list, providers must keep their licenses and enrollments current.
Submission Methods	Providers can mail or fax their submissions to the Office for Citizens with Developmental Disabilities (OCDD) in Baton Rouge.
Issued Date	The current version of the form was issued on July 30, 2020, and replaces all prior issuances.

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