How to Fill Out Form OCDD-PF-20-005

Form OCDD-PF-20-005 at a glance

What it is: Medicaid Freedom of Choice List for Waiver Services: Provider Request.

Who signs: Sign in Provider's Signature and Title, and enter the Date.

What to bring and attach to Form OCDD-PF-20-005

The following must be included with all submissions:

Completed FOC Form

A copy of your current license

Include a copy of your current Medicaid Provider Enrollment Letter(s) with all submissions.

A filled-in Form OCDD-PF-20-005 example: a new provider requests PCA Attendant in ROW

Form OCDD-PF-20-005 example filled out, example: a new provider requests PCA Attendant in ROW — Sample Care LLC fills out the Freedom of Choice provider request. It offers PCA Attendant in ROW, Community Living Supports, in Region 4, so other provider types stay empty. The picture shows page 1, and none of its entries is real. Nothing goes in 06 Professional Services [NOW], Therapists: Physical, Occupational and Speech, or Dietician, Skilled Nursing and Social Worker because the agency offers none of them. Previous Information is left blank because the agency has no former name or address. Provider Toll-Free Phone Number is left blank because the agency has no toll-free line.

How to fill out Form OCDD-PF-20-005, box by box

Place, update or remove the agency

Place, update or remove the agency on or from the Freedom of Choice list for the provider type(s) checked.

Current Information and Previous Information

Print or type ALL Information Requested.

Under Current Information, enter the Provider Name, the Provider Address (Include City, State, Zip) and the Provider Contact Name; under Previous Information, enter the Former Name, Former Address and Former Provider Contact Name.

Include the area code in the Phone and Fax Number(s) for Current Information and for Previous Information; also enter the Provider Toll-Free Phone Number and Provider E-Mail, or the Former Provider Toll Free Phone Number and Former Provider E-Mail.

Children's Choice and its therapies

Check 03 Children's Choice (Children's Choice Waiver), 03 (7T) Art Therapy, 03 (7Z) Hippotherapy, 03 (7V) Music Therapy, 03 (7Y) Horseback Riding or 03 (7R) Aquatic Therapy, and enter the Region(s).

06 Professional Services [NOW]

Under 06 Professional Services [NOW], check all applicable services: Psychologist, Social Worker, Nutritional/Dietary, and enter the Region(s).

Shared Living, Pre-Vocational, Day Habilitation and Monitored In Home Caregiving

Each of these has Region(s): 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) and 35 Monitored In Home Caregiving (ROW).

Therapists: Physical, Occupational and Speech

35 Physical Therapist, 37 Occupational Therapist and 39 Speech Therapist each print CC 4 W (ROW) and Both CC and ROW, with Region(s).

Personal Care Attendant (PCA)

For 82 (4W) PCA Attendant in ROW (Check one), check Community Living Supports, Companion Care Support or Both CLS and CCS, and enter the Region(s); 82 Personal Care Attendant (PCA) has Region(s).

Respite, Substitute Family Care, Adult Day Health Care, Supervised Independent Living and Supported Employment

Form OCDD-PF-20-005 example filled out, respite, Substitute Family Care, Adult Day Health Care, Supervised Independent Living and Supported Employment

83 Center-Based Respite, 84 (4W) Substitute Family Care: NOW or ROW, 85 (4W) ROW Adult Day Health Care (ADHC), 89 Supervised Independent Living (SIL) - (NOW) and 98 Supported Employment each have Region(s).

Provider's Signature and Title

If your situation is different

A change in the above noted information

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 on page 1 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.

Common questions about Form OCDD-PF-20-005

Where do I file it?

Mail or Fax to: OCDD/Waiver Supports & Services 628 North 4th Street, 2nd Floor Baton Rouge, LA 70802 Fax: (225) 342-8823

Sources

[1] Form OCDD-PF-20-005 (Issued 01/12/2022), Medicaid Freedom of Choice List for Waiver Services: Provider Request, Louisiana Department of Health (the Official source link on this page).

OCDD-PF-20-005 PDF Details

Print or type all information requested, under Current Information and Previous Information.

Changes: it is the provider's responsibility to notify the Louisiana Department of Health (LDH), Waiver Supports and Services, of any changes within ten (10) days.

License: to keep from being removed from the FOC list, a provider's license and enrollment must be kept current.

Required with all submissions: a completed FOC Form, a copy of your current license, and a copy of your current Medicaid Provider Enrollment Letter(s).

Licensing: this notice will NOT notify DXC Provider Enrollment or Licensing regarding these changes.

Question	Answer
Form Name	OCDD-PF-20-005
Form Length	2 pages
Fillable?	Yes
Fillable fields	98
Avg. time to fill out	17 min
Edition	Issued January 12, 2022
Where to send	Mail or fax to OCDD/Waiver Supports & Services, 628 North 4th Street, 2nd Floor, Baton Rouge, LA 70802; fax (225) 342-8823
Other names	OCDD-PF-20-005, OCDD PF 20 005, Louisiana Freedom of Choice, FOC form, Freedom of Choice List, Medicaid Freedom of Choice List for Waiver Services
Official source	OCDD-PF-20-005 (Rev January 12, 2022), Louisiana Department of Health

OCDD-PF-20-005: Louisiana Medicaid Freedom of Choice List for Waiver Services: Provider Request