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Provider Forms

 

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.

Forms 

Healthy Louisiana Plan Notification of Pregnancy Form (PDF 116.11 KB)
Prior Authorization Fax Request Form
(PDF 205.4 KB)

 

EPSDT Personal Care Services Forms

EPSDT Personal Care Services Daily Schedule (PDF 33.22 KB)
EPSDT Personal Care Services Plan of Care
(PDF 70.71 KB)
EPSDT Personal Care Services Social Assessment
(PDF 60.25 KB)
EPSDT Personal Care Services Form (90 Days)
(PDF 61.01 KB)
UHC Community Plan Prior Authorization Form
(PDF 323.34 KB)

 

Pediatric Day Health Care Program (PDHC)

Effective Sept. 1, 2016, the forms below must be used when requesting prior authorization for Pediatric Day Health Care (PDHC) services program by the Louisiana Department of Health (LDH). The changes in the PDHC program have been published in the PDHC Provider Manual here. Please contact your Provider Relations Representative with any questions.

Pediatric Day Health Care Program (PDHC) Place of Service Code Notice - Effective October 1, 2016 (PDF 146.82 KB)

 

Pediatric Day Health Care Forms 

PDHC Prior Authorization Checklist (PDF 32.28 KB)
PDHC Physician's Order
(PDF 318.68 KB)
UHC Community Prior Authorization Form
(PDF 323.34 KB)