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To order KIDMED program
materials, click here. |
Educational/Outreach/Promotional Materials
Keep Your Child Healthy Brochure
Front
Page (PDF Format) • Back
Page (PDF Format)
Screening Periodicity Schedule
PDF Format • Word Document
Vaccine
Schedule
PDF Format
Optional KIDMED Universal Screening
Documentation Tools
Birth through
5 Years Initial
PDF
Format • Word
Document
Birth through
5 years Periodic
PDF
Format • Word
Document
6 to 21 Years
Initial
PDF Format
• Word
Document
6 to 21 Years
Periodic
PDF Format
• Word
Document
Provider Enrollment Forms/Documents
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: KIDMED,
5700 Florida Blvd., 10th Floor, Baton Rouge, LA 70806
Louisiana Provider Interest Letter
PDF Format
• Word Document
Services
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
Privacy
Policy I Site
Map
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