Hospital Presumptive Eligibility Library

Forms

• BHSF Form 1-HPE – Assessment Tool for Hospital Presumptive Eligibility (HPE) Only
• BHSF Form 2-HPE – Hospital Presumptive Eligibility Qualified Entity (HPEQE) Application
• BHSF Form 3-HPE – Responsibilities and Agreement (Representative Only)
• BHSF Form 4-HPE – Responsibilities and Agreement (Authorized Agent Only)
• BHSF Form 5-HPE – Qualified Entity Log
• BHSF Form 6-HPE – HPEQE RightFax Transmittal

To be authorized as an HPEQE, your facility must submit the following forms to HPE@LA.gov:

1. Form 2-HPE (signed by Facility Authorized Agent) and listing all representatives and their contact information;
2. Each representative listed on the 2-HPE should complete and sign a Form 3-HPE;
3. Form 4-HPE (signed by Facility Authorized Agent); and
4. Training certificates for each representative listed on Form 2-HPE

Once all required documents are received you will be sent an email indicating your facility has been approved as an HPEQE.

Resources

• Summary Sheet
• Z-200 Chart (from Medicaid Eligibility Manual)
• HPE Provider Manual
• BHSF Form 1-A – General Application for Health Coverage

Email forms to HPE@la.gov or fax to 225-389-2741 or 877-747-0985.

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