The 24 Louisiana forms clinicians complete, from workers' comp treatment requests and OMV medical forms to Medicaid drug prior authorization, LHSAA physicals and the LaPOST.
This page lists the Louisiana forms clinicians complete, grouped by program, and each group links to its program hub. On workers' comp claims, providers request treatment under the Medical Treatment Schedule on LWC-WC 1010, and the carrier answers on the same form. The Office of Motor Vehicles uses DPSMV 2302 for a driver's medical exam, DPSMV 2301 for vision and DPSMV 1966 for a mobility impaired hang tag or plate. Louisiana Medicaid and every Healthy Louisiana plan take the Uniform Prescription Drug Prior Authorization Form, 450.
The carrier must answer a 1010 within 5 business days. Silence counts as a denial, which the provider can take to the OWCA Medical Director on form 1009 within 15 calendar days. OMV medical and vision forms go back within 30 days of issue. School immunization certificates print from the LINKS registry. LASERS pays for its annual physician statement when a copy of the bill is included. The LHSAA physical and the LaPOST come in Spanish. Vero Documents fills PDF forms from the visit note and the chart.
Health care provider's request for prior authorization of treatment or testing under the Louisiana Medical Treatment Schedule, with the carrier's approval, modification or denial on the same form.
Asks the OWCA Medical Director to review a denied, modified or deemed-denied 1010 request, or to grant a variance from the Medical Treatment Schedule.
LWC-WC 1010ACarrier's first request for missing minimum information on an authorization request, with a section for the health care provider's response.
Attending physician gives ICD-10 diagnoses, symptoms, treatment, progress and functional restrictions to support a LASERS member's disability retirement (LASERS standard: disabled from the member's state position).
Physician's report of history, findings, diagnosis and prognosis supporting a TRSL member's disability retirement application (also used for a disabled child's survivor benefit with Form 12PDMC).
Annual physician report confirming that a TRSL disability retiree's disabling condition continues, with objective findings and prognosis.
Form MSD12Attending physician's report used by LASERS to decide whether a disability retiree's benefits continue (diagnosis, findings, progress, functional abilities), with a section to bill LASERS for the report.
DPSMV 2301Optometrist's or ophthalmologist's report of visual acuity (each eye and both) and opinion on driving from a vision standpoint.
DPSMV 2302Physician's report (history, neurological, cardiopulmonary, mental, diabetes, hearing, etc.) on an applicant's ability to safely operate a motor vehicle when OMV suspects a physical or mental infirmity.
DPSMV 3005Reports a suspected unsafe driver based on firsthand knowledge of driving behavior or a medical/physical condition.
Certifies a permanent or temporary mobility impairment for a mobility impaired (handicap) hang tag or license plate (R.S. 47:463.4).
Uniform prescription drug prior authorization request used by Louisiana Medicaid fee-for-service and every Healthy Louisiana MCO under the single preferred drug list.
Prescriber's request and medical necessity attestation for Medicaid-covered disposable incontinence products.
Medical history and physical exam clearance required for participation in LHSAA athletics.
Written statement from the attending health care provider permitting an athlete to return to competition after a concussion or head injury (La. R.S. 17:436.1).
Certificate of required immunizations that Louisiana schools must receive before enrollment under R.S. 17:170, prepopulated from the LINKS immunization registry.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Clinician referral documenting medical necessity for a WIC-issued breast pump (e.g. infant hospitalization, prematurity, maternal condition).
Physician order form based on the person's condition and preferences covering CPR, scope of treatment and artificial nutrition for patients with life-limiting or irreversible conditions.
Online reporting of reportable diseases and conditions under the Louisiana Sanitary Code (Title 51) by providers, facilities and labs.
Online non-urgent report, or written follow-up to an oral report, of suspected child abuse or neglect by a mandated reporter.
Written report of suspected child abuse/neglect by a mandated reporter, either as the initial report or as the follow-up required within five days of an oral report (Children's Code art. 610 D).
Online non-urgent report of suspected abuse, neglect or exploitation of an adult aged 60 or older.
Physician certification (or optometrist/ophthalmologist for vision) that a hunter meets the Physically Challenged Hunter Program criteria (wheelchair, ambulatory, amputee, vision classes), for the matching permit.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Five business days. The provider completes Sections 1 and 2 of LWC-WC 1010, with diagnosis, CPT and ICD codes, the treatment requested and the required minimum information, signs Section 5 and faxes or emails it to the carrier. If the carrier asks for missing information on form 1010A, the clock stops until the provider answers in Section 3. No answer in time is a deemed denial.
A medical examiner or physician, who must give a state license number. DPSMV 1966 certifies a permanent or temporary mobility impairment. A permanent impairment gets a 4-year hang tag, and certification is needed only at the first application. A temporary one gets a 1-year tag with one renewal, which needs a new certification. The applicant takes the form to an OMV office, adding DPSMV 1799 for a plate.
Print it from LINKS, the state immunization registry. Providers with LINKS access can print the Certificate of Immunizations when the child is up to date and the certificate has not expired, and the immunization history fills in from the registry. There is no blank paper version. The parent gives it to the school or child care, which must receive it before enrollment.
The attending health care provider: a licensed physician, nurse practitioner or physician assistant. They complete the LHSAA Return to Competition Form with the athlete's details, dates, their Louisiana medical license number and signature, and the student gives it to the school. If the provider recommends that the athlete not continue, that recommendation may not be overruled.