GENERAL INFORMATION FOR PRESCRIBER-ONLY Please Note: The Basic Packet is not required for assignment of a prescriber-only provider number. This prescriber-only provider number does not enable the provider to be reimbursed for any medical services for Louisiana Medicaid recipients. The attached form is used to issue a provider number to the following out of state (only) professional individuals if allowed to prescribe medications by their governing board: • • • • • • •
Physicians (MD) Doctor of Osteopathic Medicine (DO) Medical Psychologist (MP) Optometrist (OD) Chiropractor (DC) Dentist (DDS) Podiatrist (DPM)
NOTE: In-state professional providers must apply using a PT PO application.
The attached form is used to issue a provider number to the following professional individual if allowed to prescribe medications by their governing board. A Pharmacist may be either In-State or Out of State. • Pharmacist
PT 33 Revised 02/2016
The following professionals must complete an entire enrollment application and are not allowed to use this form to obtain a prescriber-only provider number: • • • • •
Completed forms may be faxed to the Molina Medicaid Solutions Provider Enrollment Unit at 225-216-6392 or mailed to: P. O. Box 80159 Baton Rouge, LA 70898-0159
PT 33 Revised 02/2016
Provider Enrollment Form – Prescriber-Only Provider Number All Fields Are Required Incomplete Forms Will Be Returned For Completion Enrollment Purpose:
Write Prescriptions
Individual Provider Name:
DC
DDS
Pharmacist
DO
DPM
MD
MP
OD
National Provider Identifier: Provider Street Address: Provider City: Provider State: Provider Phone Number:
Provider Zip:
(
)
-
Provider Fax Number: Provider Email:
(
)
-
Social Security Number: Date of Birth: Professional License Number: (attach copy of license) Specialty (refer to attached lists): Requested Effective Date: Date of Signature: Everything Below This Line Is For Internal Use Only Sanction Databases Checked: SAM LIEI/OIG NPPES CMS Monthly Report State Exclusion Database Checked By: Date Checked: Requesting Pharmacy Name Requesting Pharmacy Provider Number Requesting Pharmacy Contact Person Requesting Pharmacy Phone Number Recipient Name Recipient Number For Files Maintenance Provider Number:
FAX Completed Forms To: Molina Medicaid Solutions Provider Enrollment Unit (225) 216-6392. Phone#: (225) 216-6370 PT 33 Revised 02/2016
Specialties and Subspecialties for Physicians Code 01 1T 02 03 04 05 06 07 08 10 13
Specialty Description General Practice Emergency Medicine / Emergency Room General Surgery Allergy Otology, Laryngology, Rhinology (ENT) Anesthesiology Cardiovascular Disease Dermatology Family Practice Gastroenterology Neurology
14
Neurological Surgery
16
Obstetrics & Gynecology (see subspecialty below) Subspecialty 3A Critical Care Medicine 3B Gynecologic Oncology 3C Maternal & Fetal Medicine
18 20 22 24 25
Ophthalmology Orthopedic Surgery Pathology Plastic Surgery Physical Medicine Rehabilitation
26 28 29 30 33 34
Psychiatry Proctology Pulmonary Diseases Radiology Thoracic Surgery Urology
Revised 01/15
Code Specialty Description 37 Pediatrics (see subspecialty below) Subspecialty 1A Adolescent Medicine 1B Diagnostic Lab Immunology 1C Neonatal Perinatal Medicine 1D Pediatric Cardiology 1E Pediatric Critical Care Med. 1F Pediatric Emergency Med. 1G Pediatric Endocrinology 1H Pediatric Gastroenterology 1I Pediatric Hematology – Oncology 1J Pediatric Infectious Disease 1K
Pediatric Nephrology
1L 1M 1N 1P
Pediatric Pulmonology Pediatric Rheumatology Pediatric Sports Medicine Pediatric Surgery
38 39 40
Geriatrics Nephrology Hand Surgery
41
Internal Medicine (see subspecialty below) Subspecialty 2A Cardiac Electrophysiology 2B Cardiovascular Disease 2C Critical Care Medicine 2D Diagnostic Lab Immunology 2E Endocrinology/Metabolism 2F Gastroenterology 2G Geriatric Medicine 2H Hematology 2I Infectious Disease 2J Medical Oncology 2K Nephrology 2L Pulmonary Disease 2M Rheumatology 2N Surgery-Critical Care 2P Surgery-General Vascular
Specialties and Subspecialties for Doctors of Osteopathic Medicine Code Specialty Description
Code Specialty Description
01
General Practice
37
1T
Emergency Medicine / Emergency Room General Surgery Allergy Anesthesiology Cardiovascular Disease Dermatology Family Practice Gynecology Gastroenterology Manipulative Therapy
02 03 05 06 07 08 09 10 12 14 2Q 15 17
23 24 25 27 28 29 31 32
Neurological Surgery Nuclear Medicine Obstetrics Ophthalmology, Otology, Laryngology, Rhinology Orthopedic Surgery Pathologic Anatomy: Clinical Pathology Peripheral Vascular Disease or Surgery Plastic Surgery Physical Medicine Rehabilitation Psychiatry, Neurology Proctology Pulmonary Diseases Roentgenology, Radiology Radiation Therapy
33 34
Thoracic Surgery Urology
20 21
Revised 01/15
Pediatrics (see subspecialty below) Subspecialty 1A 1B 1C 1D 1E 1F 1G 1H 1I 1J 1K 1L 1M
