Email Member Services | MCNA Dental: Louisiana Medicaid and CHIP

Complete an Oral Health Assessment Form

Your Full Name

Your Email Address

Your Phone Number

Your Relationship to the Member

Member's First Name

Member's Middle Name

Member's Last Name

Member's Date of Birth

Member ID Number

Member's Primary Language

Name of Member's Health Plan

Member's Street Address

Member's City

Member's State

Member's Zip Code

Please answer each of the below questions:

Dentist's First Name

Dentist's Last Name

Dentist's Phone Number

Dentist's Street Address

Dentist's City

Dentist's State

Dentist's Zip Code