Mental Health Rehab Form Member First Name *Middle NameLast Name *Member Birth DateMonthDayYearMember ID *Email AddressConfirm Email AddressMember informationI am requesting services from a mental health rehabilitation (MHR) provider. I understand that I have the right to choose an agency to provide services to me or my child. I understand that I may receive MHR services only from one provider, unless my health plan grants an exception. I may change providers if I am not satisfied with the services. If assistance is needed in finding an MHR provider, review the list of providers on your health plan’s website below. Or call your assistance plan. 1. Aetna: www.aetnabetterhealth.com/louisiana/find-provider or call 1-855-242-0802 (TTY/TDD 711). 2. Amerihealth Caritas Louisiana: www.amerihealthcaritasla.com/member/eng/tools/find-provider.aspx or call 1-888-756-0004 (TTY 1-866-428-7588). 3. Healthy Blue: www.myhealthybluela.com/la/care/find-a-doctor.html or call 1-844-227-8350 (TTY /TTD 711). 4. Louisiana Healthcare Connections: https://providersearch.louisianahealthconnect.com or call 1-866-595-8133 (TTY/TTD 711). 5. United Healthcare Community: www.uhccommunityplan.com/la/medicaid/healthy-louisiana.html or call 1-866-675-1607 (TTY 1-877-4285-4514). The provider that I have freely selected to deliver MHR services to me, or my child, is: Provider name: The Gift Mental Health Clinic, LLC Provider phone number: 504-644-2575 Provider contact name: Will Bell Provider address: 3301 Canal Street #1, New Orleans, LA 70119Member/legal guardian signatureBy signing the form below, I understand that I have chosen to receive services from this MHR provider, and I acknowledge that it is my responsibility to notify my previous provider so they can coordinate my care with my new provider. I understand that I am free to choose any MHR provider in my health plan’s network.Start signing your signature hereYour browser does not support e-Signature field.Printed legal guardian name (if applicable)Provider’s informationA Member Choice form is required before receiving any mental health rehabilitation services. This form requires the member/legal guardian’s signature, date, the identified provider’s telephone number, and contact name. The provider is responsible for coordinating the transition of care with the member’s previous provider before starting services.Submit
