Louisiana Medicaid Application Center Resource Library


Josie McElroy


Fax: (225) 376-4736


IMPORTANT: This webinar was regarding your Application Center data and our new computer system. We need someone with knowledge of all aspects of the Application Center, including payment details and satellite locations (probably the AC Manager) to complete the spreadsheet. The deadline for submitting this information is January 31, 2018


Use your computer to complete the spreadsheet; handwritten spreadsheets will not be accepted.

If you do not submit the spreadsheet with your facility information by January 31, 2018, you will have to wait to sign up using the new system on July 30, 2018. Please ensure that your facility can continue to take Medicaid applications when we go live by turning in your data by January 31, 2018.


Click here to view a recording of the webinar: https://register.gotowebinar.com/register/5711072689716096769


Application Center Data Conversion Spreadsheets

EXAMPLE WORKBOOK - General Hospital

LaMEDS AC Registration Workbook


Application Center Websites

AC Demo Changes/Replacement Cards  
App Center Online Training  
Online Application  


Application Center Documents

Application Center Evaluation  
Application Center Handbook


AC-2 and addendum (Application Center Contractual Agreement & HIPAA Business Associate Addendum)


AC-2a (Standard Board Resolution Form)


AC-3 (Confidentiality Responsibilities / Agreement)


AC-4 (Application Center Request for Representative Training)


AC-5 (Log of Referrals) Instructions

AC-7 (RightFAX Cover and Transmittal Log)


AC-8 (Inspection / Monitoring Report)


AC-8a (Monitoring Corrective Action Results)


AC Signage Template


AR (Consent for Authorized Representation)


Clearance (Statement of Applicant)


Electronic Funds Transfer (EFT) Enrollment Form  

General Application

General Application - Additional Persons  
General Application - Employer Coverage Tool  
General Application - Appendix D - Personal Assets  
General Application - Spanish  
General Application - Vietnamese  
Health Plan Non-Timely Filing Procedures  
Healthy LA Comparison Chart - Printout  
Healthy LA Comparison Chart - Web Viewing  
HIPAA 202L (Authorization to Release Health Information)  

HIPAA 402P (Authorization to Release or Obtain Health Information)


Ins-LR (Request for Life Insurance Policy Information)


MS (Social Information Interview)


MS/C (Child's Medical & Social Interview)


Resources (Request for Resources & Interest Income Information)


Verification (Application Verification Request Form)


Voter Registration Application (LR-1 & 1M)


Voter Registration Declaration (English)


Voter Registration Declaration (Spanish)

Voter Registration Declaration (Vietnamese)  

Voter Registration Poster (English)


Voter Registration Poster (Spanish)


Voter Registration Poster (Vietnamese)


Wages (Personal Wage Record)

WIC 38 Flyer