• Resources
• LDH Resources

LDH Resources

• HIPAA 402P - Authorization to Release or Obtain Health Information

  Details:

  October 29, 2016

  • Medicaid

  Application Center Forms, Medicaid Forms, Confidentiality Forms, Other Medicaid Forms, Medicaid Forms Library

  Downloadable Assets:

  HIPPA 402P - Authorization to Release or Obtain Health Information HIPPA 402P - Authorization to Release or Obtain Health Information - Instructions HIPPA 402P - Authorization to Release or Obtain Health Information - Spanish

• Application Center Signage Template

  Details:

  September 15, 2016

  • Medicaid

  Application Center Forms, Flyers, Posters

  Downloadable Assets:

  Application Center Signage Template Application Center Signage Template - Spanish

• HIPAA 101P - Notice of Privacy Practices

  Details:

  July 31, 2016

  • Medicaid

  Application Center Forms, Medicaid Forms, Confidentiality Forms, Other Medicaid Forms, Medicaid Forms Library

  Downloadable Assets:

  HIPPA 101P - Notice of Privacy Practices HIPPA 101P - Notice of Privacy Practices - Spanish HIPPA 101P - Notice of Privacy Practices - Vietnamese

• BHSF Form 1-HPE - Assessment Tool for Hospital Presumptive Eligibility (HPE) Only

  Details:

  June 30, 2016

  • Medicaid

  Application Center Forms, HPE Forms, Hospital Presumptive Eligibility Forms, Medicaid Forms Library

  Downloadable Assets:

  BHSF Form 1-HPE - Assessment Tool for Hospital Presumptive Eligibility (HPE) Only

• BHSF Form AC-5 - Log of Referrals

  Details:

  April 25, 2016

  • Medicaid

  Application Center Forms

  Downloadable Assets:

  BHSF Form AC-5 - Log of Referrals BHSF Form AC-5 - Log of Referrals - Instructions

• Clearance Form - Additional Statements and Notes

  Details:

  June 12, 2015

  • Medicaid

  Application Center Forms

  Downloadable Assets:

  Clearance Form - Additional Statements and Notes Clearance Form - Additional Statements and Notes - Instructions

• Provider Request for Spend-Down Medically Needy Notice

  Details:

  May 01, 2015

  • Medicaid

  Application Center Forms, Medicaid Provider Forms, Medicaid Forms Library

  Downloadable Assets:

  Provider Request for Spend-Down Medically Needy Notice

• BHSF Form AC-8a - Monitoring Corrective Action Results

  Details:

  September 26, 2014

  • Medicaid

  Application Center Forms

  Downloadable Assets:

  BHSF Form AC-8a - Monitoring Corrective Action Results BHSF Form AC-8a - Monitoring Corrective Action Results - Instructions

• BHSF Form MS - Social Information Interview Form

  Details:

  June 27, 2014

  • Medicaid

  Application-Center-Forms, Medicaid-Forms, Other-Forms, Other-Medicaid-Forms

  Downloadable Assets:

  BHSF Form MS - Social Information Interview Form BHSF Form MS - Social Information Interview Form - Spanish BHSF Form MS - Social Information Interview Form - Instructions BHSF Form MS - Social Information Interview Form - Work History Supplement

• BHSF Form 4-HPE - Responsibilities and Agreement (Authorized Agent Only)

  Details:

  February 28, 2014

  • Medicaid

  Application Center Forms, HPE Forms, Hospital Presumptive Eligibility Forms, Medicaid Forms Library

  Downloadable Assets:

  BHSF Form 4-HPE - Responsibilities and Agreement (Authorized Agent Only)

• BHSF Form 3-HPE - Responsibilities and Agreement (Representative Only)

  Details:

  January 31, 2014

  • Medicaid

  Application Center Forms, HPE Forms, Hospital Presumptive Eligibility Forms, Medicaid Forms Library

  Downloadable Assets:

  BHSF Form 3-HPE - Responsibilities and Agreement (Representative Only)

• BHSF Form 5-HPE - Qualified Entity Log

  Details:

  December 31, 2013

  • Medicaid

  Application Center Forms, HPE Forms, Hospital Presumptive Eligibility Forms, Medicaid Forms Library

  Downloadable Assets:

  BHSF Form 5-HPE - Qualified Entity Log