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Get Louisiana Medicaid Mileage Reimbursement

ENROLLMENT PACKET FOR THE LOUISIANA MEDICAL ASSISTANCE PROGRAM Louisiana Medicaid Program Friends and Family Transportation Enrollment packet subject to change without notice PT 42 Revised 04/14 FRIENDS AND FAMILY TRANSPORTATION PROVIDER ENROLLMENT FORM This section is for Provider Enrollment Unit use only Driver Parish Code Begin Date Provider End Date This Friends and Family Enrollment Form is for / Rep New Enrollment Extension Recertification Add-On Trans Please fill out the entire form below. Incomplete forms will be rejected which will delay the enrollment date. Please print* Driver Information Mr. Ms. Date of Birth of Driver // Full Name of Driver Last First Middle Initial Maiden if applicable Mailing Address of Driver Street or P. O. Box City State ZIP Code Parish of Driver Telephone Number of Driver Social Security Number of Driver I will transport the following people limited to total of 5 individuals Medicaid Recipient Name mm/dd/yyyy Medicaid Plastic Card Control Number 16 digit CCN Number on Medicaid Card Check off the boxes and fill in the information below A. I have a current Louisiana Driver s license that is not suspended or revoked* Yes No Driver s License Number car. Car License Plate C. I carry liability insurance on my car and it is at least the minimum* Name of Insurance Company I promise/attest that all of the above information is true and accurate. I understand that false statements regarding this information can result in fines penalties and/or imprisonment. Print Name of Driver Signature of Driver Date of Signature Signature must be witnessed by two individuals who are NOT FAMILY MEMBERS or PARTICIPANTS and who are 18 years of age or older. Print Name of Witness 1 Signature of Witness 1 Please mail to Provider Enrollment Unit PO Box 80159 Baton Rouge LA 70898-0159. Incomplete forms will be rejected which will delay the enrollment date. Please print* Driver Information Mr. Ms. Date of Birth of Driver // Full Name of Driver Last First Middle Initial Maiden if applicable Mailing Address of Driver Street or P. Ms. Date of Birth of Driver // Full Name of Driver Last First Middle Initial Maiden if applicable Mailing Address of Driver Street or P. O. Box City State ZIP Code Parish of Driver Telephone Number of Driver Social Security Number of Driver I will transport the following people limited to total of 5 individuals Medicaid Recipient Name mm/dd/yyyy Medicaid Plastic Card Control Number 16 digit CCN Number on Medicaid Card Check off the boxes and fill in the information below A. O. Box City State ZIP Code Parish of Driver Telephone Number of Driver Social Security Number of Driver I will transport the following people limited to total of 5 individuals Medicaid Recipient Name mm/dd/yyyy Medicaid Plastic Card Control Number 16 digit CCN Number on Medicaid Card Check off the boxes and fill in the information below A. I have a current Louisiana Driver s license that is not suspended or revoked* Yes No Driver s License Number car.

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