BHSF FORM 1-HPE
REV 02/16
Assessment Tool for Hospital Presumptive Eligibility (HPE) Only
Facility ______________________________________________
HPE Provider Number
_______________________________
Date of Interview_________________ Parish of Residence______________________________________
Section A. Individual’s Information
Individual’s Name
Date of Birth
Social Security Number (optional)
Mailing Address (Include City, State, Zip Code)
Daytime Phone
Street Address (if different) (Include City, State, Zip Code)
Other Phone
Gender
E-mail Address
Male
Female
Section B. Applicant Screening Questions
1. Have you received Presumptive Eligibility
5. What is your expected delivery date?
No
within the last 12 months?
Yes
Are you a US Citizen or have eligible immigration status?
2.
Yes
No
6. Are you currently receiving Medicaid?
Yes
No
Yes
3. Are you a Louisiana resident?
7. Were you a foster child at age 18?
Yes
No
No
8. Do you receive Medicare?
4. Are you pregnant?
Yes
Yes
No
No
Section C. Category/Income Assessment
Name
DOB
Income
Relationship to
Is this a child in your
Applicant
care?
SELF
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Total Household income from the column above _____________________________
Children under age 19
Based on the above attested information, __________________________, is presumptively eligible for ___________________________
from _______________ until ________________ or until a Medicaid Determination is made if a Louisiana Medicaid application is submitted
HPEQE completed BHSF 1-A
prior to the end of the period indicated above. Individual was assisted in applying for Medicaid by:
In the event a previous period or HPE eligibility was given within the last 12 months, individual was informed that this assessment will
be denied.
Date
Interviewer’s Signature
Interviewer’s Printed Name
Interviewer’s Phone Number
Interviewer’s Email