Dom of choice form louisiana 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'Current Information' section. Enter the Provider Name, Address, and Contact details accurately. Ensure all fields are completed as this information is crucial for processing.
3. If applicable, provide 'Previous Information' by entering any former names or addresses. This helps maintain a comprehensive record.
4. In the services section, check all applicable provider types and services you wish to include on the Freedom of Choice list. Be thorough to ensure all relevant services are selected.
5. Complete the signature section at the bottom of the form. The Provider’s Signature and Title must be included along with the date to validate your submission.
6. Finally, ensure that you attach any required documents such as your current license and Medicaid Provider Enrollment Letter before submitting via mail or fax.

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