Louisiana Medicaid Freedom of Choice List Form – Fill Out and Use This PDF

Louisiana Medicaid Freedom of Choice List Form is designed to give citizens more autonomy and flexibility when managing their financial portfolio. This form is notable in its ability to deliver greater insight and control over individual wealth while also bringing a sense of convenience never before achieved by other methods. It constitutes a choice list put together by experts that help every investor gain access to unique and marketable investments from an offshore location, as well as take advantage of prospects from across the globe. As such, the Louisiana Medicaid Freedom of Choice List Form is an innovative tool for those wishing to increase their financial security further.

Louisiana Medicaid Freedom of Choice List Form PDF Details

Are you looking to make an important decision about your health care options in Louisiana? Look no further than the Louisiana Medicaid Freedom of Choice List Form. This form is part of a legislative mandate that allows Louisiana residents access to their basic healthcare rights, and it is essential for any individual who wants to ensure they are choosing their top option for treatment or coverage. By reading through this blog post, you can learn more about what this form entails; what its benefits are; and how you can go about getting one from the government. Keep reading to get all the information you need!

Question	Answer
Form Name	Louisiana Medicaid Freedom of Choice List Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	Form 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			:
	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

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

With the help of the online tool for PDF editing by FormsPal, you may fill out or change Form OCDD-PF-20-005 here and now. To retain our tool on the forefront of efficiency, we work to implement user-driven capabilities and enhancements on a regular basis. We're always thankful for any suggestions - play a vital part in reshaping PDF editing. It just takes several basic steps:

Step 1: Click the orange "Get Form" button above. It is going to open our editor so you could start filling in your form.

Step 2: Using this state-of-the-art PDF file editor, it's possible to do more than merely fill out blank form fields. Express yourself and make your docs look perfect with customized text added, or adjust the original content to excellence - all supported by the capability to insert any images and sign the PDF off.

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.

Step 3: Prior to moving on, check that all blanks were filled in properly. Once you establish that it's good, press “Done." Join us now and instantly obtain Form OCDD-PF-20-005, all set for download. Every single modification made is handily saved , helping you to edit the form later on if necessary. We do not share or sell any information you enter while dealing with forms at FormsPal.

Louisiana Medicaid Freedom of Choice List Form – Fill Out and Use This PDF

Louisiana Medicaid Freedom of Choice List Form PDF Details

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