Skip to Navigation
Skip to Main Content
Agency Directory
|
Phone Directory
|
Online Services
Search BMS
Agency Directory
|
Phone Directory
|
Online Services
Fee Schedules
Gainwell
HCPCS/Drug Codes
Hospital Based Presumptive Eligbility
Currently selected
How to Become a HPBE provider
HPBE Frequently Asked Questions
General Presumptive Eligibility (PE)
Hospital-Based Presumptive Eligibility (HBPE)
How to Become a PE Provider
Policy Manuals
Pharmacy
Provider News
Search BMS
WVDHHR
>
Bureau for Medical Services
>
Providers
>
Hospital Based Presumptive Eligbility
>
How to Become a PE Provider
How to Become a PE Provider
Page Content
PE Enrollment Instructions
Forms:
Word Version
PDF Version
Application to Determine Presumptive Eligibility for Medicaid
Application to Determine Presumptive Eligibility for Medicaid
Administrative User Agreement
Administrative User Agreement
Data Release Agreement
HIPAA Business Assoication Agreement
Updated July, 2016
HIPAA Business Association Agreement
Updated July, 2016
Application for PE Addendum for use of Third Party Vendors
Application for PE Addendum for use of Third Party Vendors