To order CommunityCARE program materials, click here.

Non-Medicaid providers must enroll in Medicaid before they can become CommunityCARE or KIDMED Providers. Non-Medicaid providers should contact the Unisys Provider Relations unit at 800-473-2783 or 225-924-5040 to request a Medicaid enrollment packet. Providers already enrolled in Louisiana Medicaid , who want to become CommunityCARE and/or KIDMED providers, should download the appropriate forms below in the format of their choice. All forms require an original signature. Completed forms should be mailed to the address below. Mailing of the completed forms to any other address will delay your enrollment.

For questions regarding certification issues, you may contact ACS at 800-609-3888 or 225-231-8104. General questions regarding CommunityCARE policies and procedures may be directed to the Unisys Provider Relations unit at the numbers above.

CommunityCARE


PE-50 CommunityCARE Provider Supplement Agreement: This form is required by all Providers enrolling in the CommunityCARE program.
PDF Format • Word Document

Services Agreement: This form must be completed if you will be a CommunityCARE PCP providing acute care to children under the age of 21 and will be subcontracting KIDMED services to another Provider.
PDF Format • Word Document

KIDMED

PE-50 KIDMED Provider Enrollment Supplement Agreement: This form must be completed if you are providing acute care to children under the age of 21 and you intend to become a certified KIDMED Provider and provide KIDMED services at this practice location.
PDF Format • Word Document

Retainer Agreement Medical Director: This form must be completed if you are a non-physician and plan to operate a KIDMED screening clinic.
PDF Format • Word Document

Miscellaneous Forms

CommunityCARE Program Medically High Risk Exemption Form: This form should be completed by the enrollee and the enrollee's physican to request an exemption from the CommunityCARE program for medically fragile and high-risk enrollees.
PDF Format • Word Document

CommunityCARE Referral Form (revised June 2006): This form is used by providers to request referral/authorization from CommunityCARE PCP's.
PDF Format • PowerPoint Document