Hospital Presumptive Eligibility 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:
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Form 2-HPE (signed by Facility Authorized Agent) and listing all representatives and their contact information;
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Each representative listed on the 2-HPE should complete and sign a Form 3-HPE;
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Form 4-HPE (signed by Facility Authorized Agent); and
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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.
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| RELATED INFO |
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- Summary Sheet
- Z – 200 Chart (from Medicaid Eligibility Manual)
- HPE Provider Manual
- BHSF Form 1-A - General Application for Health Coverage
| FAX NUMBERS |
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