Please note: Many of these forms are currently being revised. To obtain the most current forms, contact the CommunityCARE hotline at 800.259.4444.

Non-Medicaid providers must enroll in Medicaid before they can become CommunityCARE or KIDMED Providers. Non-Medicaid providers should contact the Unisys Provider Enrollment Unit at 225.216.6370 to request a Medicaid enrollment packet, or should go to http://www.lamedicaid.com and follow the appropriate link for Provider Enrollment. Providers already enrolled in Louisiana Medicaid, who want to become CommunityCARE and/or KIDMED providers, should download the appropriate forms below in the format of their choice. All forms require an original signature. Completed forms should be mailed to the address below.

Automated Health Systems
10101 Siegen Lane
Building 3, Suite B & C
Baton Rouge, LA 70810
Attn: CommunityCARE/KIDMED Program

Download any of the following forms in the format of your choice.

For questions regarding site certification issues, you may contact AHS at 225.757.4366. General questions regarding CommunityCARE policies and procedures may be directed to the Unisys Provider Enrollment Unit at 225.216.6370.

Downloads:

CommunityCARE/KIDMED Services Agreement

	Download 93 KB

	Download 31 KB

CommunityCare Provider Handbook

	Download 788 KB

	Download 177 KB

CommunityCARE Program Medically High Risk Exemption Form

This form should be completed by the enrollee and the enrollee's physican to request an exemption from the CommunityCARE program for medically fragile and high-risk enrollees.

	Download 29 KB

	Download 31 KB

CommunityCARE Referral Form (revised June 2009)

This form is used by CommunityCARE PCPs to refer their CommunityCARE enrollees for medically appropriate services the PCP does not provide (i.e.: specialty care, post authorizations of emergency services, etc…)

	Download 118 KB

	Download 52 KB

PE-50 CommunityCARE Provider Enrollment Supplement Agreement

http://www.lamedicaid.com/provweb1/provider_enrollment/newenrollments.htm

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