OAAS Forms

Forms for various programs and services offered through the Office of Aging and Adult Services:

• LT-PCS Rights and Responsibilities Form
• Statement of Medical Status & Instructions
• MFP/My Place LA Form
• LTPCS Service Log and Instructions
• CCW Service Log and Instructions
• Request for Payment Override Form and Instructions
• Confidentiality Consent for Shared PAS and LT-PCS
• Legally Responsible Individual (LRI)/Spouse Request Form
• PACE Request for Nursing Facility Level of Care: Deemed Continued Eligibility or Permanent Waiver of Annual Recertification

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Mailing Address: Louisiana Department of Health | P. O. Box 629 | Baton Rouge, LA 70821-0629
Physical Address: 628 N. 4th Street | Baton Rouge, LA 70802 | PHONE: 225-342-9500 | FAX: 225-342-5568
Medicaid Customer Service 1-888-342-6207 | Healthy Louisiana 1-855-229-6848