Hospital Presumptive Eligibility Statement Of Interest (Page 2 of 4) in pdf

Hospital Presumptive Eligibility Statement Of Interest Page 2

Qualified Entity Application for Hospital Presumptive Eligibility

This is an application to become a Qualified Entity for Hospital Presumptive Eligibility for the purposes of

offering Presumptive Eligibility to your patients. You must participate as a Medicaid provider to perform

Hospital Presumptive Eligibility determinations. Please complete, sign, and return this application to [State

agency].

If you have questions about this application or the Hospital Presumptive Eligibility program, contact [State

agency] at: [phone number] or [email address].

1. Name of hospital

Other name (if any used for provider services)

2. County

Telephone number

FAX number

(

)

(

)

3. Mailing address (no P.O. Box) for Site

City

4. Contact person

Telephone number

FAX number

(

)

(

)

Please estimate the number of patients your hospital sees each month that are not covered by health insurance or Medicaid at the time of their visit.

I hereby certify that all the above information is true and accurate to the best of my knowledge.

Signature

Title of Authorized Agent

Date

Hospital Presumptive Eligibility Statement Of Interest Page 2