Provider Enrollment - Applications for New Enrollments, Reactivations, and Change of Ownership
Louisiana Medicaid provider enrollment applications are now available online. Enrolling in Louisiana Medicaid is a two- (2) step process:
1. Download the Basic Enrollment Packet.
2. Download the additional Enrollment Packet that is applicable to each provider type.
* It is necessary to submit forms from both packets for enrollment requests to be processed.
Unnecessary delays may be avoided by reviewing the packets in their entirety prior to completing. Incorrect/incomplete applications will be
returned to the provider for correction. A checklist has been provided in each provider specific packet identifying all
required forms/documentation for enrollment. Carefully review the instructions and checklist prior to submission to ensure that
all paperwork is complete. All required documentation must be submitted as one application – do not send required documentation
separately as it will be rejected.
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Basic Provider Enrollment Packet for Entities/Businesses - 06/10
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CommunityCARE Enrollment Packet - 10/09
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KIDMED Enrollment Packet (for Currently Enrolled Medicaid Providers Wanting to Add KIDMED Services) - 10/09
Provider Type Specific Packets/Checklists
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33 Prescriber-Only (Radiology Prior Authorization and/or Prescriptions)
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43 Case Management - Nurse Home Visits for First-Time Mothers