Healthy Louisiana Mental Health Rehabilitation Member Choice Form

Member Information: I 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 only receive MHR services from one provider unless my health plan makes an exception. I may change providers if I am not satisfied with the services.

If assistance is needed with finding an MHR provider, review the list of providers located at your health plan’s website below or call your plan for assistance.

1. Aetna: https://www.aetnabetterhealth.com/louisiana/find-provider or call 1-855-242-0802 Hearing impaired

2.Amerihealth Caritas Louisiana: http://www.amerihealthcaritasla.com/member/eng/tools/find-provider.aspx

or call 1-888-756-0004; TTY 1-866-428-7588

3.Healthy Blue: https://www.myhealthybluela.com/la/care/find-a-doctor.html or call 1-844-227-8350 (TTY 711)

4.Louisiana Healthcare Connections: https://providersearch.louisianahealthconnect.com/ or call 1-866-595

5.United Healthcare Community: http://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 :	Hco Behavioral Health services , LLC
Provider Phone Number:	225-261-7143
Provider Address :	11408 Lake Sherwood Ave N Suite A, Baton Rouge, LA 70816

By 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.