Medicaid Services Chart Signature Page 6/2025 Meeting 2

Receipt of Louisiana Medicaid Services Chart Written Acknowledgement Form
Support Coordinator's Email
example@example.com
Participant's initials
By signing this form you agree that you have received a copy and that your support coordinator reviewed the Louisiana Medicaid Services Chart.
Participant's Name
Form Revised Date
On this Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Recipient Name PRINT
Recipient's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Receipt of Louisiana Medicaid Services Chart Written Acknowledgement Form