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42 Friends and Family Transportation (ROW) - Louisiana Medicaid 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Driver Information. Fill in the driver's full name, date of birth, mailing address, parish, telephone number, and social security number. Ensure all fields are completed accurately.
- List the names and dates of birth of up to five individuals you will transport. This section is crucial for compliance with Medicaid requirements.
- Check off the boxes confirming you have a valid Louisiana driver’s license, a current state inspection sticker on your vehicle, and liability insurance. Provide the necessary details for each requirement.
- Sign and date the form at the bottom. Remember that your signature must be witnessed by two individuals who are not family members or participants.
- Once completed, save your document and submit it as instructed to ensure timely processing of your application.
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medicaid travel reimbursement form
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