Loading
Get Louisiana's Medicaid Program Provider Enrollment Form Group ...
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Louisiana's Medicaid Program Provider Enrollment Form Group online
Completing Louisiana's Medicaid Program Provider Enrollment Form is essential for linking or unlinking Medicaid provider numbers to group numbers. This guide will assist you in filling out the form accurately and efficiently online.
Follow the steps to complete the form successfully.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin filling in the individual provider name as it appears on the Medicaid Management Information System (MMIS) provider file.
- Enter the National Provider Identifier (NPI) in the designated field. If required, ensure that you have obtained an NPI number beforehand.
- Input the seven-digit Medicaid provider number for the individual that needs to be linked to the group.
- Provide the complete area code and telephone number where the individual provider can be reached.
- Fill in the group provider name that the individual wishes to connect with.
- Enter the group provider number, which is also a seven-digit Medicaid provider number associated with the group.
- Select the appropriate option to indicate whether you are requesting a linkage or unlinkage.
- If applicable, enter the effective date of linkage to indicate when the connection should be activated.
- For unlinkage requests, specify the termination date of unlinkage, indicating when the individual stopped providing services with the group.
- After completing all fields, ensure your information is correct and then save your changes.
- Finally, download or print the completed form for your records and submit the original to the Provider Enrollment Unit at the address provided.
Start filling out your Louisiana Medicaid Program Provider Enrollment Form online today!
Right-click on the axis and select "Format Axis" from the drop-down menu. In the "Format Axis" pane that appears on the right-hand side of the screen, select the "Axis Options" tab. Under "Bounds," you can manually set the minimum and maximum values for the axis scale. Click "Close" to apply the changes.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.