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Please Check One: New FOC Request Update existing FOC ...

Please Check One: New FOC Request Update existing FOC ... 2026

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The document is a Medicaid Freedom of Choice (FOC) request form for providers offering waiver services. It allows providers to submit new requests, update existing information, or notify about agency closures. The form requires detailed provider information, including names, addresses, contact details, and the specific services offered across various regions. Providers must ensure their information is current to remain on the FOC list and are responsible for notifying the Louisiana Department of Health of any changes.

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Click ‘Get Form’ to open it in the editor.
Begin by selecting either 'New FOC Request' or 'Update existing FOC information' based on your needs. This selection is crucial as it determines the subsequent fields you will need to complete.
Fill in the 'Current Information' section, including the effective date and provider name. Ensure all details are accurate to avoid processing delays.
In the 'Previous Information' section, provide any former names and addresses, along with contact details. This helps maintain a clear record of changes.
Check the applicable services under 'Please place/update/remove...' and specify the regions for each service type selected. This ensures that your request is processed correctly.
Finally, sign and date the form at the bottom before submitting it through our platform for a seamless experience.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (85 Votes)
2019	4.2 Satisfied (120 Votes)
2011	4.4 Satisfied (33 Votes)

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Please Check One: New FOC Request Update existing FOC ... 2026

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