Louisiana Medical Eligibility Determination Form

Submit the completed form via email to the appropriate Louisiana Department of Health office. If sending by fax, use the designated fax number listed on the form. You can also mail the completed form to the address provided on the form for processing. Ensure all required signatures are obtained before submission for swift processing.

Important dates for submitting this form include annual review deadlines and service eligibility cut-off dates that vary by month. For accurate dates, refer to the Louisiana Department of Health's official calendar or the guidelines provided in the form. Ensure timely submissions to avoid disruptions in care and services needed.

The purpose of the Louisiana Medical Eligibility Determination Form is to evaluate the eligibility of individuals applying for services under the Louisiana Department of Health. This form collects essential information about the applicant's medical background, care needs, and living arrangements. By accurately submitting this form, applicants can gain access to critical support services designed for individuals with developmental disabilities.

• 1. Applicant's Name: The full name of the person applying.
• 2. Address: Includes city, state, zip code, and parish of the applicant.
• 3. SS #: Social Security number of the applicant.
• 4. Medicaid #: Medicaid identification number of the applicant.
• 5. Responsible Party/Curator: Details of the individual responsible for the applicant.
• 6. Living Arrangements: Information regarding where the applicant resides.
• 7. Previous Facility Care: Records past care received at facilities.
• 8. Home/Community-Based Services: Services used or considered for the applicant.
• 9. Diagnosis: Medical diagnosis related to the applicant's condition.
• 10. Medications: Details about any medications being taken.
• 11. Mental Status/Behavior: Assessment of the mental state and behavior of the applicant.
• 12. Activities of Daily Living: Assessment of the applicant's basic daily living skills.
• 13. Special Care/Procedures: Information on any special medical care required.
• 14. Physical Examination: Results from the physical examination conducted.
• 15. MD Signature: Signature of the attending physician validating the form.

Failure to submit this form can result in delays in obtaining the necessary medical and support services. Without proper submission, eligibility may not be assessed, causing disruptions in care continuity. It is essential to ensure all sections of the form are completed accurately and submitted on time.

• Missed Deadlines: Submitting late may lead to the ineligibility for timely care and services.
• Inaccurate Information: Incorrect details can delay the approval process and create obstacles in receiving assistance.
• Lack of Documentation: Not providing required documentation can result in immediate disqualification from receiving support.

• 1. Transitioning Care: Use this form when moving from one service provider to another.
• 2. Initial Applications: Necessary for first-time applicants seeking eligibility for services.
• 3. Annual Reviews: Required for annual assessments to continue eligibility.