Get La Pt 42 2014-2025

The LA PT 42 form is essential for providers seeking to enroll in the Louisiana Medicaid Non-Emergency Medical Transportation Program. This guide provides clear, step-by-step instructions to help users fill out the form accurately and effectively, ensuring compliance and a smooth application process.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the LA PT 42 form and open it in your preferred editor.
2. Start by filling out your provider's name in the designated section. Ensure that the name matches the registration details with the Louisiana Secretary of State.
3. Enter the provider's contact information, including the geographical address, phone number, and email address. Make sure all information is accurate and current.
4. Proceed to outline the ownership type by selecting the appropriate option: sole owner, partnership, corporation, or government. This is essential for identifying the entity's business structure.
5. List all direct or indirect owners with a controlling interest in the business. Be thorough in providing their names, addresses, and telephone numbers for transparency.
6. Complete the Hold Harmless Agreement that must be notarized. Attach it to your application to signify understanding and compliance.
7. Indicate the total number of drivers employed by your service. Each driver must complete a Driver Enrollment Form (MT-8), which should accompany your application packet.
8. Provide information regarding the service area, listing the parishes where transportation services will be provided along with the number of vehicles in each parish.
9. Ensure that all vehicle requirements are met, including insurance coverage and vehicle registration details. Each vehicle must be registered under the business name.
10. Once completed, review all sections to confirm accuracy. Save any changes you made, and you will have the option to download, print, or share the form for submission.

Encourage others to fill out their necessary documents online to streamline their enrollment process.