PCPs are responsible for assuring the HEBA is administered during the Initial Health Assessment to each IEHP Member within 120 days of the Member's enrollment. The HEBA form is available in seven different languages and in five separate age categories.
Printed English and Spanish versions are available through your IPA or you can get the forms you need by simply clicking on the links below.
You will need Adobe Acrobat Reader 4 or later to view the PDF files. You can download a free copy by clicking below.
Chinese
1. DHS 7098-A (0-3)
2. DHS 7098-B (4-8)
3. DHS 7098-C (9-11)
4. DHS 7098-D (12-17)
5. DHS 7098-E (18 and older)
English
1. DHS 7098-A (0-3)
2. DHS 7098-B (4-8)
3. DHS 7098-C (9-11)
4. DHS 7098-D (12-17)
5. DHS 7098-E (18 and older)
Hmong
1. DHS 7098-A (0-3)
2. DHS 7098-B (4-8)
3. DHS 7098-C (9-11)
4. DHS 7098-D (12-17)
5. DHS 7098-E (18 and older)
Lao
1. DHS 7098-A (0-3)
2. DHS 7098-B (4-8)
3. DHS 7098-C (9-11)
4. DHS 7098-D (12-17)
5. DHS 7098-E (18 and older)
Russian
1. DHS 7098-A (0-3)
2. DHS 7098-B (4-8)
3. DHS 7098-C (9-11)
4. DHS 7098-D (12-17)
5. DHS 7098-E (18 and older)
Spanish
1. DHS 7098-A (0-3)
2. DHS 7098-B (4-8)
3. DHS 7098-C (9-11)
4. DHS 7098-D (12-17)
5. DHS 7098-E (18 and older)
Vietnamese
1. DHS 7098-A (0-3)
2. DHS 7098-B (4-8)
3. DHS 7098-C (9-11)
4. DHS 7098-D (12-17)
5. DHS 7098-E (18 and older)