Apply for LA HAP

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

CLINICIAN SUPPLEMENTAL FORM FOR HCV TREATMENT REGIMENS
To be completed by medical provider as part of the Hepatitis C sub-program application.

Additional LA HAP forms

CERTIFICATION OF LOUISIANA RESIDENCY
Use this form to certify that you are a Louisiana resident if you are unable to provide another form of verification.

CERTIFICATION OF NO INCOME/CASH 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, you may need to give this form to your employer Human Resources department so they may submit it to HIP.  HIP will usually initiate this process for you.

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.

LA HAP/GUARDIAN DENTAL PLAN ENROLLMENT FORM
Submit this pre-filled form to enroll in the LA HAP/Guardian Dental Plan.  Only member name and date of birth are required.

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.