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Louisiana Department of Health & Hospitals | Kathy Kliebert, Secretary

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Statewide Initiatives



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Hospital Presumptive Eligibility Forms

Forms


 

To be authorized as an HPEQE, your facility must submit the following forms to HPE@LA.gov:

  1. Form 2-HPE (signed by Facility Authorized Agent) and listing all representatives and their contact information; 
  2. Each representative listed on the 2-HPE should complete and sign a Form 3-HPE;
  3. Form 4-HPE (signed by Facility Authorized Agent); and
  4. 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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FAX NUMBERS
  • 1.877.747.0985
  • 1.225.389.2741
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