Get Basic Enrollment Packet For Entities/businesses (with Instructions)
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How to fill out the Basic Enrollment Packet for Entities/Businesses (With Instructions) online
Filling out the Basic Enrollment Packet for the Louisiana Medical Assistance Program is an essential step for entities and businesses seeking to enroll as Medicaid providers. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.
Follow the steps to successfully complete your enrollment packet.
- Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
- Begin by entering your Louisiana Medicaid provider number in the designated field. If you are applying for a new enrollment, leave this section blank.
- Indicate the type of application by checking the appropriate box for either new enrollment, update to existing enrollment, reactivation, or change of ownership.
- Provide your National Provider Identifier (NPI) in the specified field, ensuring it is a 10-digit number.
- Fill out Section A, which includes entity/business information and practice location details, including the DBA name, business address, and contact information.
- In Section B, enter the Provider Pay-To Name that matches the IRS documentation exactly. Fill in the mailing address where correspondence will be sent.
- For hospitals or long-term care facilities, complete Section C by providing certified bed numbers and the name of the facility administrator.
- Section D requires the date for which you want the enrollment to be effective. Ensure this complies with timely filing policies.
- Provide contact information in Section E, including the name, phone number, fax number, and email of the individual responsible for the enrollment.
- In Section F, review the attestation requirements, ensuring the authorized representative provides their signature and date.
- Double-check all information entered for accuracy, sign the document in blue ink, and prepare any necessary additional documentation.
- Once completed, save the document, and proceed to print or share the form as required for submission.
Start your enrollment process by filling out the Basic Enrollment Packet online today!
In Louisiana, Medicaid is often referred to as the Louisiana Medicaid program. It provides healthcare coverage to eligible individuals and families. To successfully enroll, use the Basic Enrollment Packet For Entities/Businesses (With Instructions) to navigate the application process. This packet will help ensure you meet all program requirements and submit the necessary documentation.
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