Louisiana Medicaid Freedom of Choice List Form PDF Details

In navigating the intricacies of health care provision under Medicaid in Louisiana, providers wrestle with numerous forms and regulations, among which stands the Louisiana Medicaid Freedom of Choice List form. A critical document, it serves as a bridge between Medicaid waiver services and eligible patients, ensuring the latter's right to select from a list of qualified providers for specific healthcare services. It encompasses fields like the provider's name, contact information, and the categories of services they offer, ranging from psychological support to skilled nursing and personal care. Moreover, the form not only facilitates initial registration but also addresses any changes in provider information, emphasizing the need for timely updates to avoid removal from the Freedom of Choice list. This procedural necessity underscores a commitment to maintaining an updated roster of service options, thereby honoring the patient’s freedom of choice as enshrined in Medicaid policies. Submitting this form, complete with a current license and Medicaid Provider Enrollment Letter, is mandatory, laying the groundwork for a structured, patient-centered approach to health care provisioning within the waiver system. Issued on July 30, 2020, it supersedes all previous versions, reflecting an ongoing effort to refine and enhance the coordination between Medicaid services and beneficiary needs.

QuestionAnswer
Form NameLouisiana Medicaid Freedom of Choice List Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesForm OCDD-PF-20-005 , Louisiana Medicaid Freedom of Choice List for Waiver Services Form

Form Preview Example

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

 

:

 

 

 

 

 

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):

 

 

 

Companion Care Support

 

 

 

 

 

 

one:

 

 

 

 

 

 

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

 

How to Edit Louisiana Medicaid Freedom of Choice List Form Online for Free

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This PDF doc needs specific details; to ensure accuracy and reliability, you need to consider the guidelines directly below:

1. It is crucial to complete the Form OCDD-PF-20-005 accurately, so be mindful when filling out the segments including these particular blank fields:

Filling out segment 1 in Louisiana Medicaid Freedom of Choice List Form

2. Just after filling out the previous section, go on to the next stage and complete the essential details in these blank fields - PreVocational, Day Habilitation, Environmental Modifications, Personal Emergency Response System, Medical Equipment and Supplies, Psychologist ROW, Monitored In Home Caregiving NOW, Monitored In Home Caregiving ROW, Physical Therapist, Occupational Therapist, Speech Therapist, Registered Dietician ROW, Skilled Nursing NOW, CC CC, and ROW.

How to fill in Louisiana Medicaid Freedom of Choice List Form portion 2

3. Through this part, look at Supported Employment, Regions, Providers Signature and Title, Date, It is the Providers Responsibility, Mail or Fax to, OCDDWaiver Supports Services, Baton Rouge LA Fax, Issued July Replaces all prior, and OCDDPF. Each one of these should be filled in with highest attention to detail.

Louisiana Medicaid Freedom of Choice List Form conclusion process shown (part 3)

Be really attentive while filling out Mail or Fax to and Providers Signature and Title, as this is where most users make a few mistakes.

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