LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS, RATE AND AUDIT REVIEW SECTION
628 N. 4th Street

Bienville Building, 2nd Floor

P.O. Box 629 (zip 70821-0629)
BATON ROUGE, LA 70802

APPLICATION FOR EXTENSION OF TIME TO FILE
MEDICAID NURSING HOME COST REPORT

1.Please provide information requested below 
for Facility (Provider):

Today's Date:

Name of Facility (Provider):

Address of Facility:

Provider Number:  Orig. Due Date:

Cost Report Period - From: To:

I request an extension of time until 
to file the cost report for the facility / cost report
period indicated above. 

Please explain why you need an extension. 
You must give an adequate explanation:

Required Signature: X_____________________________________

2. Please provide information requested below for Applicant
(Contact): 

Full Name:         
Title:              
Company Name:       
Address 2/Street:   
Address 3:          
City / State / Zip: 
Phone / Ext:         Fax:  

3. Please submit this Application For Extension Of 
Time To File (twice) to: 

Initially Via Fax To: Fax: (225) 342-1834 
                      Rate and Audit Review
                      Second Floor                       
                      Phone: (225) 342-6116
                      

       AND 

Follow-up Via USPS To: 
(Address appearing at the top of this form)