Get La Medicaid Freedom Of Choice (foc) List For Waiver Services Provider Request 2019-2025

Filling out the LA Medicaid Freedom Of Choice (FOC) List for Waiver Services Provider Request online is a crucial step for providers seeking to offer services in Louisiana. This guide will walk you through each section of the form with clarity and support, ensuring you provide the necessary information correctly and efficiently.

Follow the steps to complete the FOC list for waiver services provider request online.

1. Click ‘Get Form’ button to obtain the form and open it in your digital document management platform.
2. Select whether you are making a new FOC request, updating existing information, or notifying the agency about service termination. Mark the appropriate option clearly.
3. In the 'Current Information' section, enter the effective date for your request.
4. Complete the provider name and address fields. Provide both your current and any former names and addresses.
5. Fill in the contact name and phone numbers for both the current and previous provider. Make sure to include the area code.
6. Enter the toll-free phone number and email for your current provider. Also, if available, provide the former toll-free number and email address.
7. Indicate the type of services you are requesting to be placed, updated, or removed from the FOC list. Check the appropriate boxes for services such as Children’s Choice, shared living, professional services, and more.
8. For each service selected, specify the regions in which these services will be offered. Ensure you provide all applicable regions.
9. In the provider's signature and title section, sign and date the form to certify that the provided information is accurate. This includes acknowledging your responsibility to notify of any changes.
10. Once completed, save the changes and ensure that all required documents, such as your current license and Medicaid provider enrollment letter, are included before submission.

Complete your LA Medicaid Freedom Of Choice (FOC) List For Waiver Services Provider Request online today to ensure timely processing.