How to Fill Out Louisiana Form 90-L: Signatures, Submission, and Appeals

To fill out Louisiana Form 90-L, have a Louisiana-licensed physician or nurse practitioner complete the three sections (Applicant Information, Level of Care, and Medical Information) using the patient’s current records, sign and date it no earlier than 30 days before admission and no later than the admission date itself, and submit it to the nursing facility or to the state office that handles the program you’re applying for. Without an approved 90-L, Louisiana Medicaid will not pay for nursing facility care, Home and Community-Based Services waivers, or Adult Day Health Care.¹

Get the Current Version of the Form

Use the fillable PDF posted by the Louisiana Department of Health on ldh.la.gov under the Office for Citizens with Developmental Disabilities waiver documents section. The most recent revision is dated June 2, 2025.² You can type into the fields before printing for the signature, or print a blank copy and complete it by hand. Nursing facilities and waiver providers usually keep blank copies on hand, so a facility social worker or case manager can supply one if you’re already working with them.

Who Must Sign, and When

A physician (MD or DO) licensed in Louisiana must sign and date the form. A nurse practitioner’s signature is also accepted. If a physician assistant completes it, a supervising physician has to be identified on the document.²

Timing is the single most common place this process goes wrong. The form cannot be signed more than 30 days before the admission date, and it cannot be signed after the date of admission. The certification is not effective any earlier than the signature date, so if the practitioner signs two weeks before the patient actually moves in, that signature date becomes the earliest possible effective date for coverage.¹ If admission gets pushed back and the 30-day window expires, the practitioner has to complete a fresh form. Don’t collect the signature too early.

Section I: Applicant Information

This section collects identifying details. Fill in the applicant’s full name, Social Security number, Medicaid number (if one has been assigned), date of birth, sex, and Medicare number. The address block includes city, state, zip code, and parish. List a responsible party or curator with their contact information and relationship to the applicant.²

Three fields in this section look optional but aren’t: current living arrangements, any previous facility care, and whether home or community-based services have been used or considered. Louisiana’s administrative code specifically requires that prior living arrangements and previous institutional care be documented.¹ The applicant or responsible party signs and dates the bottom of the section.

Section II: Level of Care

The practitioner marks the level of care the patient requires. Options include ICF/IID (Intermediate Care Facility for Individuals with Intellectual Disabilities) and Skilled Care, with checkboxes for special designations such as TDC, ID, and NRTP (Complex or Rehab). One question in this section carries real weight: whether home and community-based services are adequate to meet the applicant’s needs. The answer steers which program the applicant can enter. Use the comments field to explain the clinical reasoning behind the level of care selected rather than leaving the choice unexplained.²

Section III: Medical Information

This is the longest section and the one reviewers scrutinize most closely. It has nine parts:

Diagnosis. List the primary diagnosis and every secondary diagnosis affecting daily functioning and safety.
Medications. Record each medication’s dosage, frequency, and route of administration. A separate line captures known allergies.
Recent hospitalizations. Document dates and reasons for any recent inpatient stays.
Mental status and behavior. Mark whether the patient is oriented, forgetful, depressed, comatose, confused, prone to wandering, hostile, or combative. Each item uses a frequency scale: 1 for seldom, 2 for frequent, 3 for always.
Communications. Note whether the patient communicates verbally or nonverbally.
Activities of daily living. For eating, bathing, personal care, ambulation, transfer, bowel incontinence, bladder incontinence, urinary catheter use, impaired vision, impaired hearing, and dentures, mark whether the patient is self-sufficient, needs assistance, or requires total help.
Special care and procedures. Covers ostomy care, glucose monitoring, restraints, IVs, suctioning, specialized rehab, infections such as MRSA, tube feeding, dialysis, respiratory care, wound care, tracheostomy care, and ventilator dependence. Where relevant, note type, frequency, size, stage, and site.
Physical examination. Record height, weight, vital signs, lab results, radiology findings, and a system-by-system exam covering head and CNS, mouth and EENT, chest, heart and circulation, abdomen, genitalia, extremities, and skin.
Practitioner identification and signature. The signing physician or nurse practitioner lists their name, phone number, and address. If a physician assistant signs, the supervising physician must be named.

The physical examination section is where most incomplete forms fall apart. Reviewers look for specific clinical findings, not just “abnormal,” to justify the requested level of care. If the patient has stage 3 pressure wounds, document the location, size, and treatment plan. If the patient wanders at night, say how often and what safety measures are in place. Vague entries invite requests for additional information that stall the certification.²

Where to Submit the Completed Form

The submission path depends on what the applicant is applying for.

Nursing facility admission. The completed 90-L goes to the facility where the applicant will reside. Facility staff process it and forward it through Medicaid’s system. A current 90-L is required on each admission and each readmission.¹
Community Choices Waiver and other Home and Community-Based Services waivers. The form goes to the Office of Aging and Adult Services for review.
ICF/IID services and developmental disability waivers. The Office for Citizens with Developmental Disabilities handles the determination.³

Keep a copy of the signed form before it leaves your hands. If a page is lost in transit or misplaced at the facility, a backup saves you from starting the certification over. Faxed and scanned copies are generally accepted for processing, though the facility or reviewing office may ask for the original for their permanent file.

One related document you shouldn’t confuse with the 90-L: anyone being admitted to a Medicaid-certified nursing facility in Louisiana also needs a completed Level 1 Preadmission Screening and Resident Review (PASRR), regardless of payment source. The PASRR screens for mental illness, intellectual disability, or related conditions that may require specialized services. It’s a separate form, but both have to be in order before admission.

What Happens After You Submit

Standard service authorization decisions are issued within 14 calendar days of the agency receiving the completed request, unless an extension is granted.⁴ The applicant or representative receives a written notice stating whether the level of care determination was approved or denied. An approval satisfies the medical eligibility component; assuming financial eligibility is also met, Medicaid can begin paying for covered services.

A denial means the reviewing agency concluded the applicant does not meet nursing-facility-level-of-care criteria based on the medical evidence submitted. Denials often trace to incomplete documentation rather than a genuine lack of medical need. If the physical examination or ADL sections were thin, the practitioner can sometimes resolve the problem by submitting supplemental medical records.

If You’re Denied, You Can Appeal

The applicant can request a fair hearing, generally within 30 days of the date on the decision notice. Fair hearings in Louisiana are handled by the Division of Administrative Law. The applicant can submit written evidence, call witnesses, and present arguments to a hearing officer, and may be represented by an attorney or patient advocate.

The strongest appeals include updated or more detailed medical records that respond to the specific reasons given in the denial. If the denial says the ADL scores did not show enough functional limitation, the treating physician should provide a narrative explaining why the checkbox scores understate the patient’s actual condition. Hearing officers review the medical evidence independently, and a well-documented appeal with specific clinical findings has a real chance of overturning the initial decision.

A Note on Financial Eligibility

Form 90-L only handles the medical side of long-term care Medicaid. Financial eligibility is evaluated in parallel, and approval on one track does not guarantee approval on the other. For 2026, a single applicant for Louisiana nursing home Medicaid can have no more than $2,000 in countable assets and income no higher than $2,982 per month, with different limits for married couples and for cases where only one spouse is applying. Louisiana also applies a five-year look-back on asset transfers.⁵ If you’re approved medically but denied financially (or the other way around), the application doesn’t move forward until both are satisfied.

False Statements Carry Criminal Penalties

Submitting false information on Form 90-L or any other Medicaid document is Medicaid fraud under Louisiana law, punishable by up to five years in prison, a fine of up to $20,000, or both.⁶ The statute reaches anyone who knowingly makes a false statement or misrepresentation of material fact in a Medicaid application or claim. For the signing practitioner, a conviction also risks loss of medical license and exclusion from Medicaid and Medicare. The penalties apply equally to applicants, family members, and providers who participate in misrepresenting a patient’s condition.

1
Legal Information Institute. Louisiana Administrative Code tit. 50 II-10349 – Requirements for Certification
2
Louisiana Department of Health. Request for Medical Eligibility Determination
3
Louisiana Department of Health. Long-Term Care
4
Louisiana Department of Health. Timeliness of UM Decisions and Notifications
5
Medicaid Long Term Care. Louisiana Medicaid (Healthy Louisiana) Long Term Care Programs
6
Justia Law. Louisiana Revised Statutes 14-70.1 – Medicaid Fraud