Specialty Change Forms

All forms must be submitted with an original signature by mailing to:

Gainwell Technologies Provider Enrollment Unit

P. O. Box 80159

Baton Rouge, La. 70898-0159

Community Choices Waiver Specialty Change Forms

Dental Provider Specialty Change Form

DOs Specialty Change Form

MDs Specialty Change Form

Medical School Residents Specialty Change Form

Personal Care Services (PCS) Specialty Form

ROW Specialty/Subspecialty Form

School Based Health Center (SBHC) Specialty Form