Nurse Practitioner Enrollment Packet For The Louisiana Medical Assistance Program Page 4
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4Louisiana Medicaid
Link/Unlink and Working Relationship Form
If additional space is needed, please copy this form before filling it out.
P
URPOSE
This form is used when an individual provider is requesting to be linked to a Professional Group or Entity.
The form permits
Linkage/Unlinkage for two separate professional groups. When linking to a group, the estimated number of hours is required. The form
also serves as documentation that a working relationship exists between an individual and a professional group. For this form to be
valid, an ORIGINAL SIGNATURE AND DATE ARE REQUIRED.
Individual Provider Name:
LA Medicaid Provider #
National Provider Identifier (NPI)
Individual Provider Number:
Professional Group Name:
LA Medicaid Provider #
National Provider Identifier (NPI)
Professional Group Provider
Number:
Effective
Termination
LINK
UNLINK
Date:
Date:
Approximate Number of Hours Worked at this
Group Per Week, if linking. (required)
Professional Group Name:
LA Medicaid Provider #
National Provider Identifier (NPI)
Professional Group Provider
Number:
Effective
Termination
LINK
UNLINK
Date:
Date:
Approximate Number of Hours Worked at this
Group Per Week, if linking. (required)
Contact Person for questions
regarding this form:
Contact Person Phone Number:
(
)
-
W
R
A
ORKING
ELATIONSHIP
GREEMENT
I am a medical professional who has a contractual agreement to see patients for the above named professional
group(s). I have recorded the approximate number of hours to be worked at each group per week in the space(s)
provided above. (I understand that upon request I must provide DHH a copy of the written contractual
agreement.)
Print Individual Provider’s Name
Individual Provider’s Signature
Date
Original signature only – colored ink (please don’t use black ink)
Mail Completed Forms To: Molina Medicaid Solutions Provider Enrollment Unit, PO Box 80159, Baton Rouge, LA
70898-0159
PT 78
Revised 08/11
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