Louisiana Department of Health & Hospitals | Kathy Kliebert, Secretary

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Statewide Initiatives

211 - Get Connected. Get Answers.

Other Medicaid Forms

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Confidentiality Forms Spanish Translation Vietnamese Translation

Authorized Representation

Allows another person to act on your behalf. How to use this form



Notice of Privacy Practices.

(Spanish) (Vietnamese)


Authorization to Release Health information to any provider.

(Spanish) (Vietnamese)


Authoriziation to Release or Obtain Health Information naming a specific provider.


Waiver of Confidentiality

General consent to release health information. How to use this form



Medicaid Flyers & Posters Spanish Translation Vietnamese Translation

Breast & Cervical Cancer

About the Breast & Cervical Cancer Program.

(Spanish) (Vietnamese)

Fair Hearings

About the Medicaid appeals process.


Family Opportunity Act

About the Family Opportunity Act Program.


Foster Care (Youth Aging Out of)

About coverage for youth who age out of the Foster Care Program.


Friends & Family Transportation

About the Friends & Family Transportation Program.



A listing of participating clinics of the Greater New Orleans Community Health Connection Program.


LaCHIP Online Flyer

About how to apply for, renew, and update case information from a personal computer from a home or library.



About the Louisiana Health Insurance Premium Payment Program.



Provides information about how the LaMOMS and LaHIPP programs can benefit expectant mothers.


Long Term Care

About the Long Term Care Program.

(Spanish) (Vietnamese)

Long Term Care Choices

About long term care options in Louisiana.

(Spanish) (Vietnamese)

Medicaid Eligibility Card

About the Medicaid card.


Medical Programs

About Louisiana Medicaid programs.

(Spanish) (Vietnamese)

Non-Emergency Medical Transportation

About transportation for Medicaid recipients.

(Spanish) (Vietnamese)

Supplemental Nutritional Assistance Program Flyer

About the benefits of the Supplemental Nutritional Assistance Program.


Voter Registration Poster

Information about how to register to vote.

(Spanish) (Vietnamese)


Other Forms Spanish Translation Vietnamese Translation

Burial Fund Designation

A form to set aside assets to be used for burial.


MS- Social Information Interview

A questionaire about an adult's medical condition. How to use this form


MS/C - Child's Medical and & Social Information

A questionaire about a child's medical condition. How to use this form


Personal Wages

A form for your employer to complete if you do not have proof of your wages.      How to use this form


Voter Registration Declaration

Used to inform the agency that you would would like to apply to register to vote.

(Spanish) (Vietnamese)

Wage Verification Request

A form used to obtain wage information of a Medicaid applicant whenever they are unable to provide this information.                                                                               How to use this form

Wage Verification Request-MPP

A form used  to obtain wage information of a Medicaid Purchase Plan applicant whenever they are unable to provide this information.                                             How to use this form