Hospital PICU Services Packet

The instructions and forms in this packet are designed to assist providers in submitting the required information for adding or changing PICUs.

  • Cover Sheet for PICUs
  • PICU Standards for Payment
  • License Application
  • Instructions for Completing Checklist for PICU Services
  • Checklist for PICU Services
  • Attestation Letter
  • Plan Review
  • Plan Review Attestation
  • Public Health
  • Louisiana Medicaid Attestation (PICU)
  • Worksheet for Hospital Beds and Rooms (licensed and non-licensed)