Publications & Forms

To order KIDMED 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: KIDMED, 5700 Florida Blvd., 10th Floor, Baton Rouge, LA 70806

Keep Your Child Healthy Brochure
Front Page (PDF Format) • Back Page (PDF Format)

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

Screening Periodicity Schedule
PDF Format • Word Document

Vaccine Schedule
PDF Format