Official Louisiana Medicaid Freedom of Choice List Template in PDF Fill Out My Document Online

Official Louisiana Medicaid Freedom of Choice List Template in PDF

The Louisiana Medicaid Freedom of Choice List form is a crucial document used by providers to request inclusion or updates on the Freedom of Choice list for waiver services. This form ensures that individuals receiving Medicaid can choose from a variety of service providers, enhancing their access to necessary care. Completing this form accurately is essential for maintaining compliance and ensuring that services remain uninterrupted.

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Structure

Document Overview

Fact Name Details
Purpose of the Form The Louisiana Medicaid Freedom of Choice List form is used by providers to request inclusion or updates to their information on the Freedom of Choice list for waiver services.
Required Information Providers must provide their current and former names, addresses, contact information, and specific services they offer in order to complete the form.
Submission Requirements Along with the completed form, providers must include a copy of their current license and a copy of their current Medicaid Provider Enrollment Letter.
Notification Responsibility Providers are responsible for notifying the Louisiana Department of Health about any changes to their information within ten days to avoid removal from the Freedom of Choice list.
Governing Law This form is governed by Louisiana Medicaid regulations, specifically pertaining to waiver services as outlined by the Louisiana Department of Health.

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Detailed Steps for Writing Louisiana Medicaid Freedom of Choice List

Filling out the Louisiana Medicaid Freedom of Choice List form is an important step for providers seeking to update their information or request inclusion on the Freedom of Choice list for waiver services. To ensure the process goes smoothly, follow these steps carefully.

  1. Print or type all information clearly. Use black or blue ink if you are filling it out by hand.
  2. Complete the Provider Name section. Enter the current name of the provider as it appears in official records.
  3. Fill in the Provider Address. Include the full address with city, state, and zip code.
  4. Provide the Provider Contact Name. This is the person who can be reached for further information.
  5. Enter the Provider Phone and Fax Numbers. Make sure to include the area code for both numbers.
  6. List the Provider Toll-Free Phone Number. If applicable, provide this information as well.
  7. Include the Provider E-Mail. This is important for communication purposes.
  8. Indicate if you want to place, update, or remove the agency. Check the appropriate box regarding the Freedom of Choice list.
  9. Select the applicable provider types. Check all that apply, such as Children’s Choice, Professional Services, etc.
  10. Specify the regions. For each service selected, indicate the relevant regions.
  11. Sign and date the form. The signature must be from an authorized representative of the provider.
  12. Prepare additional documents. Include a copy of your current license and a copy of your current Medicaid Provider Enrollment Letter(s).
  13. Submit the form. Mail or fax it to the address provided on the form.

After completing these steps, ensure that all information is accurate and complete before submission. Keeping your information up to date is essential for maintaining your status on the Freedom of Choice list.

Form Preview

MEDICAID FREEDOM OF CHOICE LIST FOR WAIVER

SERVICES: PROVIDER REQUEST

Please Print/Type ALL Information Requested:

 

Current Information

 

Previous Information

 

 

 

 

Provider Name:

 

Former Name:

 

 

 

 

Provider Address (Include City, State, Zip):

Former Address:

 

 

 

Provider Contact Name:

Former Provider Contact Name:

 

 

ProviderPhone- FaxNumber(s)(Includeareacode):

PreviousProviderPhone- FaxNumber(s)(Includeareacode):

Phone:

Fax:

Phone:

Fax:

 

 

Provider Toll-Free Phone Number:

Former Provider Toll Free Phone Number:

 

 

 

Provider E-Mail

 

Former Provider E-Mail

 

 

 

 

Please place/update/remove the above-named agency on/from the Freedom of Choice list for the provider type(s) checked below.

 

03

Children’s Choice (Children’s Choice Waiver)

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

06

Professional Services [NOW]

 

 

 

 

 

 

 

 

 

Checkallapplicableservices:

Psychologist

SocialWorker

Nutritional/Dietary

 

Region(s):

 

 

11

Shared Living (ROW)

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

13

Pre-Vocational

 

 

 

 

 

Region(s):

 

 

14

Day Habilitation

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

15

Environmental Modifications

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

16

Personal Emergency Response System (PERS)

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

17

Medical Equipment and Supplies (Assistive Devices)

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

31

Psychologist (ROW)

 

 

 

 

 

Region(s):

 

 

33

Monitored In Home Caregiving (NOW)

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

35

Monitored In Home Caregiving (ROW)

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

35

Physical Therapist

CC

ROW

Both CC and ROW

 

Region(s):

 

 

37

Occupational Therapist

CC

ROW

Both CC and ROW

 

:

 

 

 

 

 

Region(s)

 

 

39

Speech Therapist

CC

ROW

Both CC and ROW

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

41

Registered Dietician (ROW)

 

 

 

 

 

Region(s):

 

 

44

Skilled Nursing (NOW)

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

44 (4W)

Skilled Nursing (ROW)

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

73

Social Worker (ROW)

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

82

Personal CareAttendant(PCA):

CC/NOW/SW

 

ROW

 

Region(s):

 

 

 

 

 

 

 

 

 

 

82 (4W)

If ROW selected above: Check

Community LivingSupports

 

 

Region(s):

 

 

 

Companion Care Support

 

 

 

 

 

 

one:

 

 

 

 

 

 

Both CLS and CCS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

83

Center-Based Respite

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

 

84

Substitute Family Care:

NOW

 

 

ROW

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

85

ROW Adult Day Health Care (ADHC)

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

89

Supervised Independent Living (SIL) – (NOW)

 

 

 

 

Region(s):

 

 

98

Supported Employment

 

 

 

 

 

Region(s):

 

 

 

 

 

 

 

 

 

 

 

Provider’s Signature and Title:

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

ItistheProvider’s Responsibility tonotifytheLouisianaDepartmentofHealth(LDH),WaiverSupportsandServices,regardinganychangesinthe above noted information within ten (10) days of any changes. To keep from being removed from the FOC list, a provider’s license and enrollment must be kept current. This notice will NOT notify DXC Provider Enrollment or Licensing regarding these changes.

The following must be included with all submissions:

Completed 1.) FOC Form, 2.) A copy of your current license, and 3. A copy of your current Medicaid Provider Enrollment Letter(s).

Mail or Fax to:

OCDD/Waiver Supports & Services

628North 4th Street, 2nd Floor Baton Rouge, LA 70802 Fax: (225) 342-8823

Issued July 30, 2020

OCDD-PF-20-005

Replaces all prior issuances

 

Misconceptions

Understanding the Louisiana Medicaid Freedom of Choice List form is crucial for providers and recipients alike. However, several misconceptions can lead to confusion. Here’s a closer look at some common misunderstandings:

  • It's only for new providers. Many believe this form is only necessary for new providers. In reality, it’s essential for both new and existing providers who need to update their information or maintain their status on the Freedom of Choice list.
  • Submitting the form guarantees inclusion on the list. While submitting the form is a step toward being listed, it does not guarantee inclusion. Providers must also ensure their licenses and enrollments are current.
  • Changes can be reported at any time. Some think they can report changes whenever they want. However, the Louisiana Department of Health requires that any changes be reported within ten days.
  • All services are automatically included. It’s a misconception that all services will be included upon submission. Providers must specifically check the applicable services they wish to include on the form.
  • Faxing the form is sufficient. Many assume that faxing the form is enough. However, it’s crucial to ensure that all required documents, such as licenses and enrollment letters, are included with the submission.
  • Only one form is needed for multiple services. Some providers think one form suffices for all services. In fact, they must indicate each service type and region separately on the form.
  • The Freedom of Choice list is permanent. It’s a common belief that once a provider is on the list, they remain there indefinitely. In truth, ongoing compliance with licensing and enrollment requirements is necessary to stay on the list.
  • Providers can ignore outdated information. Some think it’s acceptable to leave outdated information on the form. This is misleading; providers must keep their information current to avoid being removed from the list.
  • The form is only for specific regions. A misconception exists that the form applies only to certain regions. In reality, it encompasses various regions and services across Louisiana.

By clearing up these misconceptions, providers can navigate the Louisiana Medicaid Freedom of Choice List form more effectively, ensuring they remain compliant and can continue to serve those in need.

Documents used along the form

The Louisiana Medicaid Freedom of Choice List form is an important document for providers offering waiver services. However, several other forms and documents are often required to ensure compliance and proper processing. Below is a list of these documents, along with a brief description of each.

  • Medicaid Provider Enrollment Application: This application is necessary for healthcare providers to enroll as Medicaid providers. It collects essential information about the provider and their services.
  • Current License: A copy of the provider's current license is required to demonstrate that they are legally permitted to offer the services they provide. This helps maintain quality and compliance.
  • Medicaid Provider Enrollment Letter: This letter confirms that a provider is officially enrolled in the Medicaid program. It serves as proof of eligibility to receive reimbursement for services rendered.
  • Provider Update Notification: This document is used to inform the Louisiana Department of Health about any changes in the provider's information, such as address or contact details, ensuring that records remain accurate.
  • Durable Power of Attorney: This form allows an individual to designate someone else to make decisions on their behalf when they are unable to do so. For more information, visit arizonapdfforms.com/durable-power-of-attorney/.
  • Service Agreement: A service agreement outlines the specific services to be provided under the Medicaid program. It helps clarify the responsibilities of both the provider and the client.

Having these documents in order can streamline the process and reduce delays in service provision. It's essential for providers to stay organized and keep all necessary paperwork up to date.