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Louisiana Department of Health & Hospitals | Kathy Kliebert, Secretary

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EIDR Medicaid Claims Request Form (Replaces MRO14) for Nursing Homes and Adult Day Health Care Facilities

Monday, May 23, 2016  |  Contact: Rate Setting & Audit 225.342.6116

Click below to download the EIDR request form and sample form for Nursing Home and Adult Day Health Care facilities.

Please submit completed request form for Nursing Home and Adult Day Health Care facilities via email to glenn.deimel@la.gov. Contact Glenn Deimel, DHH Rate Setting and Audit Section, with questions or requests for information at 225-342-6116 or glenn.deimel@la.gov.

For EIDRs for Hospitals, Hospital Based Rural Health Clinics, Free Standing Psych and Hospital Distinct Part Psych, contact  Allyson.lamy@la.gov.