You'll find all forms we currently use in the following list.
We're currently reviewing all forms in an effort to make it easier and simpler to work with us, so check back frequently to see what's changed.
Botulinum Toxins Prior Authorization Form (PDF 512.07 KB)
Immune Globulin Prior Authorization Form (PDF 231.78 KB)
Gaucher's Disease Enzyme Therapy Prior Authorization Form (PDF 228.93 KB)
Prior Authorization Fax Request Form (PDF 95.64 KB)
Healthy Louisiana Plan Notification of Pregnancy Form (PDF 292.04 KB)
This notice gives care providers an overview of the policy changes made to the Pediatric Day Health Care (PDHC) program by the Louisiana Department of Health (LDH) . Effective Sept. 1, 2016, the newly revised forms below must be used when requesting prior authorization for PDHC services. The outlined changes in the PDHC program have been published in the PDHC Provider Manual here.
If you have questions about the changes, please contact your Provider Relations Representative. Thank you.