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To order CommunityCARE program materials, click here. |
Please
note: Many of these forms are currently being revised. To obtain the most
current forms, contact Unisys Provider Relations Unit at 1-800-473-2783.
Download any of the following forms in the format of your choice. All
forms that can be downloaded require an original signature - so please
print them out, sign (original) and mail them to: CommunityCARE,
5700 Florida Blvd., 13th Floor, Baton Rouge, LA 70806
NOTE:
The CommunityCARE and KIDMED Provider Enrollment forms must be submitted
as a double sided form. Please download form, copy to a 2 sided form,
and then sign with original signature before mailing. The Department of
Health and Hospitals can only accept a signed 2 sided form.
Keep
Your Child Healthy Brochure
Front
Page (PDF Format) • Back
Page (PDF Format)
CommunityCARE
Program Medically High Risk Exemption Form
PDF
Format • Word
Document
CommunityCARE
Referral Form
PDF
Format • Word Document
Louisiana
Provider Interest Letter
PDF
Format • Word Document
Services Agreement
PDF Format • Word
Document
PE-50
Community Care Provider Supplement Agreement
PDF
Format • Word Document
PE-50
KIDMED Provider Enrollment Supplement Agreement
PDF
Format • Word Document
Professional Supplement to Provider Enrollment Form BHSF PE-50
PDF
Format • Word Document
State
of Louisiana Bureau of health Services Financing Provider Enrollment Form
(BHSF PE-50)
PDF
Format • Word Document
Disclosure
of Ownership and Control Interest Statement Form 1513 (HCFA-1513)
PDF
Format • Word Document
Disclosure of Ownership and Control Interest Statement Instructions (HCFA-1513)
PDF Format • Word
Document
Health Care Financing Administration (HCFA) Civil Liberties Compliance
Policy Statement
PDF
Format • Word Document
Retainer
Agreement Medical Director
PDF
Format • Word Document
Screening
Periodicity Schedule
PDF
Format • Word Document
Vaccine
Schedule
PDF
Format
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ACS, Inc, 2004. All rights reserved.
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