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The Louisiana Medicaid Freedom of Choice List form is an essential document for providers seeking to offer waiver services to individuals in need. This form enables providers to request the addition, update, or removal of their agency from the Freedom of Choice list. It requires detailed information, including the provider's name, contact information, and previous details if applicable. Additionally, the form specifies various services that providers may offer, such as children's choice waivers, personal emergency response systems, and skilled nursing services. Each service is associated with specific regions, allowing for tailored support based on geographical needs. Providers must ensure that all information is accurate and up-to-date, as it is their responsibility to notify the Louisiana Department of Health about any changes within ten days. To maintain their position on the Freedom of Choice list, providers must keep their licenses and Medicaid enrollment current. Submissions must include the completed form, a copy of the current license, and a Medicaid Provider Enrollment Letter. The importance of this form cannot be overstated, as it plays a crucial role in ensuring that individuals receive the necessary care and support in their communities.

Sample - Louisiana Medicaid Freedom of Choice List Form

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

 
Click for PDF

Form Information

Fact Name Details
Purpose The form is used to request changes to the Medicaid Freedom of Choice list for waiver services in Louisiana.
Provider Information Providers must provide their current and previous names, addresses, and contact information.
Services Offered Providers can check multiple services, including Children’s Choice Waiver, Professional Services, and more.
Regions Each service has specific regions in Louisiana where it applies, indicated on the form.
Submission Requirements To submit the form, include a current license and Medicaid Provider Enrollment Letter.
Notification Responsibility Providers must notify the Louisiana Department of Health of any changes within ten days.
Current License Providers must keep their license and enrollment current to avoid removal from the Freedom of Choice list.
Contact Information The form must be mailed or faxed to the OCDD/Waiver Supports & Services in Baton Rouge.
Issued Date The form was issued on July 30, 2020, and replaces all prior issuances.
Governing Law This form is governed by Louisiana state Medicaid regulations.

Detailed Guide for Filling Out Louisiana Medicaid Freedom of Choice List

Filling out the Louisiana Medicaid Freedom of Choice List form is an important step in ensuring that your provider information is accurate and up to date. Once completed, you will need to submit the form along with required documents to the appropriate address or fax number.

  1. Print or type all information: Use clear and legible handwriting or a typewriter to fill out the form.
  2. Provider Name: Enter the current name of the provider.
  3. Former Name: If applicable, provide the previous name of the provider.
  4. Provider Address: Fill in the current address, including city, state, and zip code.
  5. Former Address: If applicable, enter the previous address of the provider.
  6. Provider Contact Name: Write the name of the current contact person at the provider's office.
  7. Former Provider Contact Name: If applicable, provide the previous contact name.
  8. Provider Phone and Fax Numbers: Include all current phone and fax numbers with area codes.
  9. Previous Provider Phone and Fax Numbers: If applicable, enter the former phone and fax numbers.
  10. Provider Toll-Free Phone Number: Provide the current toll-free number, if available.
  11. Former Provider Toll-Free Phone Number: If applicable, list the previous toll-free number.
  12. Provider E-Mail: Enter the current email address of the provider.
  13. Former Provider E-Mail: If applicable, provide the previous email address.
  14. Check applicable services: Mark all services that apply to the provider.
  15. Region(s): Specify the regions associated with each service checked.
  16. Provider’s Signature and Title: Sign and print the name and title of the person completing the form.
  17. Date: Write the date the form is completed.

Make sure to include a copy of your current license and a copy of your current Medicaid Provider Enrollment Letter with your submission. Once everything is ready, you can mail or fax the documents to the designated address or fax number provided.

Obtain Answers on Louisiana Medicaid Freedom of Choice List

  1. What is the Louisiana Medicaid Freedom of Choice List form?

    The Louisiana Medicaid Freedom of Choice List form is a document that allows providers of waiver services to request inclusion, update, or removal from the Freedom of Choice list. This list is essential for ensuring that individuals receiving Medicaid services can choose their preferred providers. It includes various types of services, such as children’s choice waivers, shared living, and personal emergency response systems.

  2. What information is required to complete the form?

    To complete the form, providers must provide detailed information, including:

    • Provider name and address
    • Contact names and phone numbers
    • Services being requested for inclusion on the Freedom of Choice list
    • Regions for the requested services

    Additionally, providers must submit a copy of their current license and Medicaid Provider Enrollment Letter along with the completed form.

  3. How often should a provider update their information on the Freedom of Choice list?

    Providers are responsible for notifying the Louisiana Department of Health about any changes in their information within ten days of the changes occurring. Keeping information up to date is crucial for remaining on the Freedom of Choice list. This includes maintaining current licenses and enrollment status.

  4. Where should the completed form be sent?

    The completed Louisiana Medicaid Freedom of Choice List form should be mailed or faxed to the following address:

    OCDD/Waiver Supports & Services
    628 North 4th Street, 2nd Floor
    Baton Rouge, LA 70802
    Fax: (225) 342-8823

    Make sure to include all required documents to ensure a smooth processing of your request.

Common mistakes

When filling out the Louisiana Medicaid Freedom of Choice List form, individuals often make several common mistakes that can delay processing or result in denial of services. Understanding these pitfalls can help ensure a smoother application process.

One frequent error is failing to provide complete information. Every section of the form must be filled out accurately. Incomplete entries, such as missing provider names or addresses, can lead to unnecessary delays. Double-checking each field for completeness is essential before submission.

Another mistake is not using the correct contact information. It is crucial to ensure that the phone numbers and email addresses provided are current and accurate. If the contact information is outdated, it may hinder communication from the Louisiana Department of Health.

Many applicants also overlook the importance of updating previous information. If there have been changes to the provider's name, address, or contact details, these must be clearly indicated. Failing to do so can create confusion and complicate the approval process.

Additionally, people sometimes neglect to check the appropriate service types that apply to their situation. The form includes various options, and selecting the correct ones is vital for ensuring that the right services are provided. Misclassification can lead to inadequate support being offered.

Submitting the form without the required attachments is another common issue. Applicants must include a copy of their current license and Medicaid Provider Enrollment Letter. Omitting these documents can result in immediate rejection of the application.

Moreover, individuals often forget to sign and date the form. A missing signature can invalidate the submission, causing further delays. Always ensure that the form is signed and dated in the designated area before sending it off.

Another mistake is not notifying the Louisiana Department of Health of changes in a timely manner. The form states that providers are responsible for updating their information within ten days of any changes. Failing to do so can result in removal from the Freedom of Choice list.

Lastly, some applicants may assume that submitting the form is the final step in the process. It’s important to follow up to confirm that the submission was received and is being processed. This proactive approach can help address any issues early on.

By avoiding these common mistakes, individuals can improve their chances of a successful application for services through the Louisiana Medicaid Freedom of Choice List. Careful attention to detail and adherence to the guidelines will facilitate a smoother experience.

Documents used along the form

The Louisiana Medicaid Freedom of Choice List form is an essential document for providers offering waiver services. Alongside this form, several other documents are commonly used to ensure compliance and proper enrollment in the Medicaid system. Below is a list of these documents, each serving a specific purpose in the process.

  • Medicaid Provider Enrollment Application: This application is necessary for providers to enroll in the Louisiana Medicaid program. It collects essential information about the provider's qualifications, services offered, and business structure.
  • Current License: A copy of the provider's current license must be submitted. This document verifies that the provider is authorized to deliver the services listed and meets state regulations.
  • Medicaid Provider Enrollment Letter: This letter confirms the provider's enrollment status with Medicaid. It includes details about the provider’s approved services and any limitations on their practice.
  • Service Verification Form: This form is used to confirm that the services provided are in alignment with the Medicaid guidelines. It ensures that all services rendered are documented and justified.
  • Change Notification Form: If there are any changes in the provider's information, this form must be submitted. It helps maintain accurate records with the Louisiana Department of Health.
  • Provider Agreement: This document outlines the terms and conditions of participation in the Medicaid program. It establishes the responsibilities of the provider and the state regarding service delivery and compliance.

These documents work together to facilitate the enrollment and compliance process for Medicaid providers in Louisiana. Ensuring that all necessary forms are completed accurately and submitted on time is crucial for maintaining eligibility and providing quality services.

Similar forms

  • Medicaid Provider Enrollment Application: This document is used by healthcare providers to enroll in the Medicaid program. Like the Freedom of Choice List form, it requires detailed information about the provider, including contact details and services offered. Both forms ensure that the provider meets Medicaid standards and is eligible to provide services.
  • Medicaid Waiver Application: Similar to the Freedom of Choice List, this application is for individuals seeking specific Medicaid waiver services. It collects personal information and service needs, ensuring that recipients receive the appropriate care. Both documents focus on eligibility and service provision under Medicaid guidelines.
  • Provider Change Notification Form: This form is used to notify Medicaid of any changes in provider information, such as address or contact details. Like the Freedom of Choice List, it emphasizes the importance of keeping Medicaid informed to ensure uninterrupted service delivery and compliance with regulations.
  • Medicaid Service Authorization Request: This document is submitted to obtain approval for specific services under Medicaid. It requires similar information about the provider and the services requested, ensuring that the services align with the recipient's needs. Both forms facilitate communication between providers and Medicaid to streamline service delivery.

Dos and Don'ts

When filling out the Louisiana Medicaid Freedom of Choice List form, it’s important to follow certain guidelines to ensure your submission is complete and accurate. Here are six things you should and shouldn’t do:

  • Do print or type all information clearly.
  • Do include both current and previous provider information when applicable.
  • Do check all applicable services for the provider types selected.
  • Do ensure that your signature and title are included on the form.
  • Don't forget to attach a copy of your current license.
  • Don't submit the form without including a copy of your current Medicaid Provider Enrollment Letter(s).

Following these guidelines will help prevent delays in processing your request. Make sure to review your form before sending it in.

Misconceptions

Understanding the Louisiana Medicaid Freedom of Choice List form can be challenging, leading to several misconceptions. Here are eight common misunderstandings about this form:

  • It is only for new providers. Many believe the Freedom of Choice List form is only for new providers. In reality, existing providers must also update their information using this form to remain on the list.
  • Submitting the form guarantees inclusion on the list. Some think that submitting the form automatically guarantees their inclusion. However, the provider must meet all requirements and keep their license current to remain on the list.
  • Only specific types of providers can use this form. There is a misconception that only certain types of providers can submit this form. In fact, various service types, including personal care attendants and skilled nursing, can use it.
  • Changes can be reported at any time. Some providers believe they can report changes whenever they wish. It is crucial to notify the Louisiana Department of Health within ten days of any changes to avoid removal from the list.
  • The form is only for Medicaid services. Many think the Freedom of Choice List form is exclusively for Medicaid services. However, it also applies to waiver services, which can include a broader range of support options.
  • Faxing the form is the only submission method. While some assume that faxing is the only way to submit the form, it can also be mailed to the designated address provided on the form.
  • Only the provider can fill out the form. There is a belief that only the provider can complete the form. However, authorized representatives can also fill it out on behalf of the provider.
  • Once on the list, no further action is required. Some providers think that once they are on the Freedom of Choice List, they do not need to take any further action. In reality, maintaining current licensing and enrollment is an ongoing responsibility.

By clarifying these misconceptions, providers can better navigate the process and ensure compliance with the requirements set forth by the Louisiana Department of Health.

Key takeaways

When filling out and using the Louisiana Medicaid Freedom of Choice List form, it is important to understand several key aspects to ensure compliance and accuracy.

  • Complete Information: All requested information must be printed or typed clearly, including current and previous provider details.
  • Provider Types: Check all applicable services and regions for the provider types you are requesting to place, update, or remove from the Freedom of Choice list.
  • Timely Notification: Providers must notify the Louisiana Department of Health of any changes to the information within ten days to avoid removal from the list.
  • Current Licenses: It is the provider's responsibility to maintain current licenses and Medicaid enrollment to remain on the Freedom of Choice list.
  • Submission Requirements: Each submission must include the completed Freedom of Choice form, a copy of the current license, and a copy of the current Medicaid Provider Enrollment Letter(s).
  • Mailing Instructions: The completed form and accompanying documents should be mailed or faxed to the designated address in Baton Rouge, LA.
  • No Automatic Notifications: Submitting the Freedom of Choice form does not automatically notify DXC Provider Enrollment or Licensing of any changes.

These takeaways provide a comprehensive overview of the essential steps and responsibilities involved in using the Louisiana Medicaid Freedom of Choice List form effectively.