Hospital Presumptive Eligibility Statement Of Interest printable pdf download

Hospital Presumptive Eligibility Statement Of Interest

Hospital Presumptive Eligibility Statement of Interest

Please indicate if your organization is interested in becoming a hospital presumptive eligibility

determination site for the [State agency’s] Hospital Presumptive Eligibility Program. Indicating your

interest does not obligate you to, preclude you from, or guarantee participation in the Hospital Presumptive

Eligibility Program.

Hospital Name: ____________________________________________________________________

Contact Name, Phone, E-mail: _________________________________________________________

 Yes, we are interested in becoming a hospital presumptive eligibility determination site.

 No, we are not interested in becoming a hospital presumptive eligibility determination site.

Please complete this form and return to [State agency] by [date].

E-mail:

Fax:

Mailing address:

Please contact [Contact name] with any questions.

E-mail:

Phone:

Comments or Questions

Hospital Presumptive Eligibility Statement Of Interest