Qualified hospital/qualified entity staff use the following forms in the presumptive eligibility process:

Form H1265, Presumptive Eligibility (PE) Worksheet — Completed by the QH/QE and used to determine if an applicant is presumptively eligible.

Form H1266, Short-term Medicaid Notice: Approved — Completed by the QH/QE and given to an individual determined presumptively eligible. This form notifies the individual about PE coverage and lists the eligibility start and end dates. If an individual takes this form to a local eligibility determination office and requests a temporary Medicaid identification card, give the person Form H1027-A, Medicaid Eligibility Verification.

Form H1267, Short-term Medicaid Notice: Not Approved — Completed by the QH/QE and given to an individual determined ineligible for PE coverage. This form explains the reason for ineligibility and how to apply for regular Medicaid.