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How to use or fill out Member Choice Form Healthy Louisiana. Accessible PDF with our platform
- Click ‘Get Form’ to open it in the editor.
- Begin by entering your Member Name (First and Last) and Member ID # at the top of the form.
- Fill in your Date of Birth (DOB) to verify your identity.
- 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.
- Select your chosen MHR provider by filling in their name, phone number, contact name, and address in the designated fields.
- Sign and date the form at the bottom to confirm your choice of provider and responsibility for notifying any previous providers.
- If applicable, have a legal guardian print their name and sign as well.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2020 | 4.8 Satisfied (117 Votes) |
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