This page informs the applicant that by accepting Medicaid, the Louisiana Department of Health has the right to get money received by the applicant or person(s) apply from other sources like insurance payments or lawsuit settlements for services that Medicaid has paid for you and/or the person(s). You must acknowledge that you have read this notice or that it has been read to you and that you understand that you agree to assign rights based on benefits received that were reimbursed by Medicaid.
Some items have an asterisk (*) next to them, indicating they are mandatory. You must fill in these items before you can continue to the next page.
Click the Print button to print this page for your reference.
If you are applying for SNAP, FITAP, and or KCSP you may click the Complete button to navigate to the end of the application where you can review the rights and responsibilities, sign, and submit the application. Please note that if you are applying for Child Support Enforcement services all required fields must be completed before you can submit your application.
Click the Next button to save and continue with the online application.
Click the Save & Exit button to exit the online application and save your progress on your application. The application is saved as Incomplete.