Provider Forms and References

• Independent Review Provider Reconsideration Request Form  
• Prior Authorization Fax Request Forms
• Prescription Drug Prior Authorization Forms
• Single Paper Claim Reconsideration Form
  

• 2020 Louisiana Disclosure FAQ
• National Disclosure Provider Roster Addendum Form
• Group Disclosure of Ownership and Control of Interest Form - Online Version
• Individual Disclosure of Ownership and Control of Interest Form - Online Version

• Request for Medicaid EPSDT Personal Care Services Form - Posted 9.30.2019
• EPSDT Personal Care Services Daily Schedule Form - Posted 9.30.2019
  
• EPSDT Personal Care Services Social Assessment Form - Posted 9.30.2019
  
• EPSDT Personal Care Services Plan of Care Form - Posted 9.30.2019
  

The following forms must be used when requesting prior authorization for Pediatric Day Health Care (PDHC) services program by the Louisiana Department of Health (LDH). Contact your Provider Relations Representative with any questions.

• Pediatric Day Health Care Program (PDHC) Physician's Order  
• Pediatric Day Health Care Program (PDHC) Prior Authorization Checklist