Get Enrollment Packet Of The Louisiana Medical Assistance Program Form

This guide provides clear and detailed instructions on how to effectively fill out the Enrollment Packet of the Louisiana Medical Assistance Program form online. Follow these steps to ensure your form is completed accurately and submitted without delays.

Follow the steps to complete the Enrollment Packet correctly.

1. Click ‘Get Form’ button to obtain the Enrollment Packet of the Louisiana Medical Assistance Program form and open it in your preferred online editor.
2. Begin with Section A, where you will enter the Individual/Entity Information and Physical Location. Provide the provider name as per the guidelines; if for an individual, use their legal name as it appears on their license.
3. Complete the contact information; this includes the area code and telephone number related to the provider’s physical location, social security number (for individuals), and the physical and mailing addresses.
4. In Section B, Pay-To Information, enter the Provider Pay-To Name, ensuring it matches the IRS documentation exactly. Fill in the address details where payments should be sent.
5. Proceed to Section C to provide Ownership Information. Ensure you check the appropriate box for the practice type or individual/entity set out in Section A.
6. If applicable, fill out Section D for Hospitals or Long-Term Care Facilities to provide specific information regarding certified beds and facility management.
7. In Section E, enter the effective date for your new Medicaid provider number and ensure to select the correct Provider Type Description & Code from the provided list.
8. Section F requires you to indicate how the Louisiana Medicaid Provider Number will be used in billing. Choose the appropriate Enrollment Status based on your needs.
9. Complete Section G by printing the provider’s name, providing an original signature, and entering the date the agreement was signed. Ensure that all fields are accurately filled out.
10. Once all sections have been completed correctly, review the entire form for accuracy. Save your changes, then download, print, or share the completed enrollment packet as needed.

Start your enrollment process now by completing the Enrollment Packet online.