Form 142 2026

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The document is a Medicaid Notice of Medical Certification from the Louisiana Department of Health and Hospitals, detailing the approval process for medical eligibility related to nursing facilities or intermediate care facilities. It outlines the conditions under which eligibility is granted or denied, including the need for prior approval before admission and the distinction between medical and financial eligibility. The form includes sections for agency representatives to indicate decisions regarding medical eligibility, Level II authority admissions, and waiver services.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Social Security Number (SSN) and Date of Birth in the designated fields at the top of the form.
Fill in the Medicaid Number, Home Address, Facility/Provider Name, and Vendor Number as required.
In Section I, indicate eligibility status by checking the appropriate box for Medicaid approval or denial. If approved, specify the Level of Care and any relevant details regarding physician involvement or treatments.
Proceed to Section II if applicable. Mark whether a Level II decision is required and provide effective dates for admissions as necessary.
Complete Section III by indicating waiver services approval status and any associated dates. Ensure all agency representative signatures are included before finalizing.

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