Follow the steps to successfully complete the LA BHSF Form 96-A

1. Click ‘Get Form’ button to obtain the form and access it in your preferred editing format.
2. Enter the beneficiary’s name in the designated field. Ensure that the name matches the information on their Medicaid records.
3. Input the beneficiary’s 13-digit Medicaid subscriber ID. This ID is crucial for identifying the beneficiary within the Medicaid program.
4. Provide the full name of the physician obtaining consent. Make sure to enter both their first and last names accurately.
5. Fill in the National Provider Identifier (NPI) number associated with the physician listed in the previous step.
6. In the section for ‘Signature of Beneficiary & Date,’ ensure the beneficiary signs and dates the form on or before the date of the hysterectomy.
7. If applicable, obtain the signature of a representative. This is required if the beneficiary is unable to sign or has a diagnosed mental incapacity. The representative must also date the form.
8. Review all entered information for accuracy and completeness. This is an important step to avoid any delays in processing.
9. Once completed, you can save the changes, download a copy of the form, print it for physical records, or share it as needed.

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