See the forms below to stay up-to-date on changes and other issues that are important to your practice.
- Entity / Group Provider Disclosure of Ownership and Control of Interest Form
- Healthy Louisiana Notification of Pregnancy Form
- Independent Review Provider Reconsideration Request Form
- Individual Provider Disclosure of Ownership and Control of Interest Form
- UnitedHealthcare Community Plan of Louisiana Prior Authorization Fax Request Form
The following forms must be used when requesting prior authorization for Pediatric Day Health Care (PDHC) services program by the Louisiana Department of Health (LDH). Contact your Provider Relations Representative with any questions.