Use this form to communicate your determination this person qualifies for presumptive eligibility. Your determination is based on the information attested to you by the individual who is applying for HPE coverage.

First Name Last Name Email

By submitting this form, you have determined this person meets all the following criteria, based on the information attested by the individual applying for HPE coverage:

  • Income does not exceed the monthly limit
  • Is a Washington resident
  • Is a U.S. citizen or meets immigration status requirements
  • Not already receiving Apple Health (Medicaid/CHIP)
  • Not had presumptive eligibility for Apple Health (Medicaid/CHIP) in the last 24 months. Or, if pregnant, has not had presumptive eligibility during this pregnancy
  • If not eligible for Medicaid, but eligible for CHIP, does not have other creditable health insurance
  • Is a member of one of the groups that qualify for presumptive eligibility:
    • Children under age 19
    • Parents and caretaker relatives
    • Pregnant women
    • Adults age 19-64 without Medicare
    • Someone applying for family planning services
    • Former foster care children who turned 18 while in Washington