HOSPITAL PRESUMPTIVE ELIGIBILITY AGREEMENT YH15-0012-Hospital Presumptive Eligibility Agreement • August 19th, 2016 • Arizona
Hospital Name: Hospital Address: Contact Person- Name Phone Email Persons making HPE decisions are: Hospital and/or clinic employees Staff of a subcontractor* under contract with the Hospital *Subcontractor: an organization under contract with a hospital to provide application assistance. (If applicable) Name and address of subcontractor of the hospital: Number of Clinic Locations Included in this Agreement: (details below)
