42 Friends and Family Transportation (ROW) - Louisiana Medicaid 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. List the names and dates of birth of up to five individuals you will transport. This section is crucial for compliance with Medicaid requirements.
4. 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.
5. 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.
6. Once completed, save your document and submit it as instructed to ensure timely processing of your application.

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