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Click ‘Get Form’ to open it in the editor.
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.
If applicable, provide 'Previous Information' by entering any former names or addresses. This helps maintain a comprehensive record.
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.
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.
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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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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What states pay you to stay home with an autistic child?

IHSS and Protective Supervision Caregiver Benefits IHSS is a California government program that provides financial support for in-home caretakers of impaired elders, persons with disabilities, and children with developmental disabilities including autism.

Can I get paid to stay home with my autistic child in Louisiana?

Parents (and other family members or friends) can be paid for personal care services only through the In-Home Support Services (IHSS) program through a 1915(j) waiver.

How to apply for a community choice waiver in Louisiana?

Applying for the Community Choices Waiver is as simple as requesting to have your name added to the Departments list. To do so, call Louisiana Options in Long-Term Care at 1-877-456-1146. People are offered the waiver based on their level of need.

What is the childrens Choice waiver in Louisiana?

The Childrens Choice (CC) Waiver began on February 21, 2001 to offer supplemental support to children with developmental disabilities who currently live at home with their families or with a foster family birth through 20 years of age.