Member Choice Form Healthy Louisiana. Accessible PDF 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Member Name (First and Last) and Member ID # at the top of the form.
3. Fill in your Date of Birth (DOB) to verify your identity.
4. In the Member Information section, indicate that you are requesting services from a mental health rehabilitation provider. Acknowledge your right to choose an agency for services.
5. Select your chosen MHR provider by filling in their name, phone number, contact name, and address in the designated fields.
6. Sign and date the form at the bottom to confirm your choice of provider and responsibility for notifying any previous providers.
7. If applicable, have a legal guardian print their name and sign as well.

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