Get Reference Material For - New Dhh Louisiana

Filling out the Reference Material For - New Dhh Louisiana is an important step for entities seeking enrollment in the Louisiana Medicaid program. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete and submit the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section I, where you need to provide the enrolling provider information. Fill in your Louisiana Medicaid Provider Number if applicable, Tax-Payer ID Number, and National Provider Identifier. If this is for a new enrollment, leave the Medicaid provider number blank.
3. Indicate the type of enrollment by checking the appropriate box — New Enrollment, Currently Enrolled, Re-Enroll, or Change of Ownership — and provide any necessary details for Change of Ownership.
4. Complete the contact information fields including Telephone Number(s), Legal Name of Entity/Business, Doing Business As (DBA) Name, and the Entity/Business Street Address. Ensure that the information matches the names on your licenses.
5. In Section II, respond to the criminal conviction disclosure questions carefully. You must check 'Yes' or 'No' and provide additional documentation if necessary.
6. For Section III, confirm whether your Tax ID is currently enrolled in a Federal/State funded healthcare program and if applicable, list the programs.
7. Proceed to provide the contact details of the individual completing the form in Section IV. Enter their full name, job title, and contact information, ensuring that all fields are filled.
8. In Section V, disclose ownership details. List all individuals and entities with a 5% or greater ownership interest. Be thorough in filling out the related sections for each individual and entity.
9. For Section VI, identify all managers/agents. Each individual or agent who is part of management must be listed with their relevant details.
10. Fill out Section VII if subcontractor information is applicable. Ensure to provide all requested details for any relevant subcontractor.
11. In Section VIII, list all individuals authorized to sign legal documents on behalf of the provider. Ensure these individuals are either owners or management as defined in previous sections.
12. Finally, review all sections in Section IX and ensure that the authorized representative signs the form in colored ink (not black) and dates the signature.
13. After completing the form, save your changes, and you can choose to download, print, or share the completed document as necessary.

Take the next step towards enrollment by completing the Reference Material For - New Dhh Louisiana online today.