Provider Forms and References
See the forms below to stay up-to-date on changes and other issues that are important to your practice.
General Forms
- Community Plan of Louisiana Independent Review Provider Reconsideration Form
- Medicaid Pre-Service Appeals or Grievance
- Obstetrical Risk Assessment Form
- Member Primary Care Physician Reassignment Form
- Prior Authorization Fax Request Forms
- Prescription Drug Prior Authorization Forms
- Corrected Claim and Claim Reconsideration Request Form
- Synagis Enrollment Form
Disclosure of Ownership
Submit a Pre-Service Appeal and or Grievance for a Medicaid Member