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Free Louisiana Medicaid Freedom of Choice List Form

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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

OCDD-PF-20-005 Issued January 12, 2022
Replaces all prior issuances
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:
Provider Phone - Fax Number(s) (Include area code):
Phone: Fax:
Previous Provider Phone - Fax Number(s) (Include area code):
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)
03 (7T)
Art Therapy
03 (7Z)
Hippotherapy
03 (7V)
Music Therapy
03 (7Y)
Horseback Riding
03 (7R)
Aquatic Therapy
06
Professional Services [NOW]
Check all applicable services:
Psychologist Social Worker Nutritional/Dietary
11 (4A) (4G) (4H)
(4J) (4L)
Shared Living (ROW)
13
Pre-Vocational
14
Day Habilitation
15
Environmental Modifications
16
Personal Emergency Response System (PERS)
17
Medical Equipment and Supplies (Assistive Devices)
31
Psychologist (ROW)
33
Monitored In Home Caregiving (NOW)
35
Monitored In Home Caregiving (ROW)
35
Physical Therapist
CC
4 W (ROW)
Both CC and ROW
37
Occupational Therapist
CC
4 W (ROW)
Both CC and ROW
39
Speech Therapist
CC
4 W (ROW)
Both CC and ROW
41 (4W)
Registered Dietician (ROW)
44
Skilled Nursing (NOW)
44 (4W)
Skilled Nursing (ROW)
73 (4W)
Social Worker (ROW)
82
Personal Care Attendant (PCA)
82 (4W)
PCA Attendant in ROW
(Check one)
Community Living Supports
Companion Care
Support
Both CLS and CCS
83
Center-Based Respite
84 (4W)
Substitute Family Care:
NOW
ROW
85 (4W)
ROW Adult Day Health Care (ADHC)
89
Supervised Independent Living (SIL) – (NOW)
98
Supported Employment
Provider’s Signature and Title:
Date:
OCDD-PF-20-005 Issued December 2, 2021
Replaces all prior issuances
MEDICAID FREEDOM OF CHOICE LIST FOR WAIVER
SERVICES: PROVIDER REQUEST
It is the
Provider’s Responsibility
to notify the Louisiana Department of Health (LDH), Waiver Supports and Services, regarding any
changes in the 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 FOC Form,
• A copy of your current license, and
• A copy of your current Medicaid Provider Enrollment Letter(s).
Mail or Fax to:
OCDD/Waiver Supports &
Services
628 North 4
th
Street, 2
nd
Floor
Baton Rouge, LA
70802 Fax: (225)
342-8823
↓ 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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