Louisiana 96 a online 2025

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The document BHSF Form 96-A is an acknowledgment form for Medicaid beneficiaries regarding the receipt of information about hysterectomy procedures. It requires the beneficiary's name, ID, physician's details, and signatures from both the beneficiary and a representative if applicable. The form emphasizes that Medicaid will not authorize payment for hysterectomies performed solely to render an individual permanently incapable of reproduction unless specific conditions are met, including informed consent.

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Click ‘Get Form’ to open the Louisiana 96 A in the editor.
Begin by entering the beneficiary’s name in the designated field. Ensure accuracy as this is crucial for identification.
Next, input the beneficiary’s 13-digit Medicaid subscriber ID. This number is essential for processing.
Enter the full name of the physician obtaining consent in the 'Physician Name' section.
Provide the NPI (National Provider Identifier) of the physician listed above in the corresponding field.
The beneficiary must sign and date the form before the hysterectomy date in the 'Signature of Beneficiary & Date' section.
If applicable, a representative may need to sign and date as well. This is required if the beneficiary cannot sign or has mental incapacity.

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How do I check my Medicaid status in Louisiana?

If you need help finding a provider in your area, please call 844-521-6941 (TTY 711), Monday through Friday from 7 a.m. to 7 p.m.

How do I report changes to Medicaid in Louisiana?

How do I report an address change? Call Medicaid Customer Service toll free at 1-888-342-6207 or go online by visiting the Medicaid Self-Service Portal to update your address. If you do not have an online account, you can create an account at any time.

What is the maximum income to qualify for Medicaid in Louisiana?

Once the enrollment process is complete, a letter will be generated and sent to the Provider at the Mailing address on file. The letter will include the Louisiana Medicaid provider number and the effective date of enrollment.

How do I find my Louisiana Medicaid provider number?

You must renew your Medicaid every year. When it is time to renew, Medicaid will send you a letter. The letter will list ways to renew. The fastest and easiest way is online.

Can I check my Medicaid status online?

Checking Your Medicaid Status Online Even if you applied for Medicaid in person or over the phone, you can still use your states website to manage your account or check your status. Go to your states Medicaid website and look for a button to register or sign up for an account. Click the button and follow the prompts.

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