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Forms and Applications

LA HAP APPLICATION     instructions       
VERSION EN ESPAÑOL       instrucciones

This application is to be used for enrollment for all LA HAP (L-DAP and HIP) services.

 

NEW LA HAP APPLICATION FOR HCV TREATMENT REGIMENS ONLY
This application should ONLY be used for enrollment into the LA HAP HCV sub-program.  This program is for Medicaid enrollees who have been denied treatment for HCV.  More details are available here.

 

Additional LA HAP forms

CERTIFICATION OF NO INCOME/CASH ONLY INCOME
• Use this form if you need to certify that you have either ZERO income or CASH income.  This form may NOT be used to certify any other form of income.

DISENROLLMENT FORM
• Use this form if you need to disenroll a client from LA HAP.

EMPLOYER INSURANCE HR FORM
• If you need HIP to pay your premiums for an employer-based insurance plan, give this form to your employer Human Resources department so they may submit it to HIP.

INSURANCE ADD/CHANGE FORM
• Use this form if you need to add or change an insurance plan, or to add or change types of insurance assistance, to your LA HAP coverage.

INFORMATION CHANGE FORM
• Use this form if you need to inform LA HAP of loss of insurance coverage, change of address, change of name, etc.

PROOF OF POSITIVITY FORM
• Use this form to verify proof of positivity.  This is especially useful for clients who are newly diagnosed or who have moved to Louisiana from another state.  It is not required as part of your application.

RELEASE OF INFORMATION (ROI) FORM
• Use this form if you want to grant permission to an agency to access and release client information to/from LA HAP.  Form MUST be initiated and signed by client. 

 

Ramsell forms

RAMSELL USER REQUEST AND CONFIDENTIALITY FORM
• For the purposes of tracking client eligibility, LA HAP grants Ramsell database access to agencies who receive Ryan White funding to conduct case management and/or who manage caseloads of at least 50 LA HAP clients.
Do NOT use this form if you are receiving an error message that your Ramsell web access has expired.  Instead, contact Ramsell Technical Support at 1-888-311-7632.)

 

Other useful information

Instructions for running reports in Ramsell (updated 11/17/16)

Ramsell Plan and Group key (updated 11/7/16)

LA HAP Confidentiality Policy (updated 2/18/16)

LA HAP Provider Letter (updated 12/18/15)

Full LDAP Pharmacy Network for uninsured and insured clients (updated 3/23/16)

L-DAP drug formulary for uninsured clients (updated 3/15/16)

2017 Federal Poverty Level Guidelines for Ryan White eligibility (updated 3/7/17)