Louisiana Medicaid Application Center Resource Library

We will be conducting an Application Center Conference Call. The call will only allow 100 participants so please share a phone line when possible.

Bring your questions as your feedback is crucial. This is your opportunity to get your questions answered.

Phone number:  1-888-278-0296; Conference ID: 4070060

Time

Thursday, November 9, 2017

10-11 am

All Regions

 

Application Center Websites

AC Demo Changes/Replacement Cards  
App Center Online Training  
Online Application  

 

Application Center Documents

Application Center Handbook

 

AC-2 and addendum (Application Center Contractual Agreement & HIPAA Business Associate Addendum)

Instructions

AC-2a (Standard Board Resolution Form)

Instructions

AC-3 (Confidentiality Responsibilities / Agreement)

Instructions

AC-4 (Application Center Request for Representative Training)

Instructions

AC-5 (Log of Referrals) Instructions

AC-7 (RightFAX Cover and Transmittal Log)

Instructions

AC-8 (Inspection / Monitoring Report)

Instructions

AC-8a (Monitoring Corrective Action Results)

Instructions

AC Signage Template

 

AR (Consent for Authorized Representation)

Instructions

Clearance (Statement of Applicant)

Instructions

Electronic Funds Transfer (EFT) Enrollment Form  

General Application

 
General Application - Additional Persons  
General Application - Employer Coverage Tool  
General Application - Appendix D - Personal Assets  
General Application - Spanish  
General Application - Vietnamese  
Health Plan Non-Timely Filing Procedures  
Healthy LA Comparison Chart - Printout  
Healthy LA Comparison Chart - Web Viewing  
HIPAA 202L (Authorization to Release Health Information)  

HIPAA 402P (Authorization to Release or Obtain Health Information)

Instructions

Ins-LR (Request for Life Insurance Policy Information)

Instructions

MS (Social Information Interview)

Instructions

Medicare Savings Program Application (1-MB)

 

MS/C (Child's Medical & Social Interview)

Instructions

Resources (Request for Resources & Interest Income Information)

Instructions

SNAP Assisted Enrollment

 

Verification (Application Verification Request Form)

Instructions

Voter Registration Application (LR-1 & 1M)

 

Voter Registration Declaration (English)

 

Voter Registration Declaration (Spanish)

 
Voter Registration Declaration (Vietnamese)  


Voter Registration Poster (English)

 

Voter Registration Poster (Spanish)

 

Voter Registration Poster (Vietnamese)

 

Wages (Personal Wage Record)

 Instructions
WIC 38 Flyer  

 

CONTACT INFORMATION

Josie McElroy

ApplicationCenter.Service@la.gov

Fax: (225) 376-4736