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The Louisiana Medicaid Freedom of Choice List form is a critical document for providers seeking to offer waiver services under the state's Medicaid program. This form facilitates the inclusion or removal of providers from the Freedom of Choice list, which is essential for ensuring that individuals receiving Medicaid services can select from a range of qualified providers. It requires detailed information, including the provider's name, address, and contact details, as well as any previous names or addresses. Providers must specify the types of services they offer, which may include children’s choice waivers, personal care assistance, and various therapeutic services, among others. Each service type has designated regions, underscoring the importance of geographical considerations in service delivery. Providers are also reminded of their responsibility to keep their information up to date; failure to do so can result in removal from the list. To ensure compliance, the form must be accompanied by a current license and Medicaid provider enrollment letter, and it must be submitted to the Louisiana Department of Health within a specific timeframe. This process is not just bureaucratic; it directly impacts the quality and accessibility of care for vulnerable populations in Louisiana.

Louisiana Medicaid Freedom of Choice List Example

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

 

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Documents used along the form

The Louisiana Medicaid Freedom of Choice List form is essential for providers seeking to update their information or request inclusion on the Freedom of Choice list. Alongside this form, several other documents are commonly used to ensure compliance and streamline the process. Below are four key documents that often accompany the Freedom of Choice List form.

  • Provider License: This document verifies that the provider is legally authorized to offer services. It must be current and submitted with the Freedom of Choice List form to maintain eligibility.
  • Medicaid Provider Enrollment Letter: This letter confirms the provider's enrollment in the Medicaid program. It provides essential details about the provider's status and should be included with the submission to ensure proper processing.
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  • Service Provider Agreement: This agreement outlines the terms and conditions between the provider and the Medicaid program. It details the responsibilities of each party and is crucial for establishing a formal relationship.
  • Change Notification Form: This form is used to report any changes in the provider's information, such as address or contact details. Timely submission of this form helps prevent issues with enrollment and service provision.

By ensuring that these documents are completed and submitted alongside the Freedom of Choice List form, providers can facilitate a smoother process and maintain compliance with Louisiana Medicaid requirements. Keeping all information up to date is essential for continued service eligibility.

Key takeaways

When filling out the Louisiana Medicaid Freedom of Choice List form, it is crucial to pay attention to detail. Here are some key takeaways to guide you through the process:

  • Complete All Sections: Ensure that every section of the form is filled out accurately. This includes both current and previous information about the provider.
  • Provider Information: Clearly list the provider's name, address, and contact details. Double-check that the information is current to avoid delays.
  • Service Selection: Mark all applicable services that the provider offers. This is essential for proper categorization and processing.
  • Region Specification: Specify the regions where services are provided. This helps in identifying the geographical area of service delivery.
  • Timely Updates: Notify the Louisiana Department of Health of any changes within ten days. This is vital to maintain your place on the Freedom of Choice list.
  • Documentation Required: Include a copy of the current license and Medicaid Provider Enrollment Letter along with the completed form.
  • Submission Method: Mail or fax the completed form and required documents to the specified address. Ensure that you use the correct fax number to avoid miscommunication.
  • Provider Responsibility: Remember that it is the provider’s responsibility to keep all information current. Failure to do so may result in removal from the list.
  • Check for Updates: Regularly review the form and guidelines for any changes or updates to the process or requirements.

By following these key points, you can ensure a smoother experience when using the Louisiana Medicaid Freedom of Choice List form. Timeliness and accuracy are essential in this process.

↓ Louisiana Medicaid Freedom of Choice List PDF