DHS 1163 at a glance
What it is: Death Payments Program Application of the State of Hawaii Med-QUEST Division, Department of Human Services.
Who signs: Interested Party/Applicant signs.
A filled-in DHS 1163 example: a niece applies after her uncle's death
How to fill out DHS 1163, box by box
I. Decedent's information
Under I. Decedent's information, enter the Decedent's Name (Last, First, M.I) and Sex.
A certified death certificate or death confirmation document from agencies with authority to confirm the death is needed and must be submitted within 60 days from the date of death. If the document is available at the time you turn in this application, please attach.
Enter the Social Security No., the Veteran - VA File Number and the Date of Birth.
Mark Yes or No: Was the individual eligible or receiving medical and/or financial services at time of death?
Enter the Date of Death.
Specify the Body Location, e.g. hospital, nursing home, mortuary or medical examiner.
II. Interested Party/Applicant's information
Under II. Interested Party/Applicant's information, enter the Interested Party/Applicant's Name (Last, First, M.I) and the Relationship/Responsibility to Decedent.
Enter the Home/Cell Phone, the Work Phone and the Interested Party/Applicant's Mailing Address.
III. Full funeral benefits
Mark Yes or No: Are any full funeral benefits available to the decedent such as but not limited to pre-paid funeral or burial plans, insurance plans, associations, and clubs? (Full funeral benefits mean funeral and/or burial services that provide a complete and dignified disposal of the decedent.)
IV. Social Security lump-sum death payment
Mark Yes or No: Has anyone received or expect to receive, the lump-sum death payment benefit from Social Security for the decedent?
V. I understand that by signing below
By signing, you understand that you are responsible for coordinating transport of the decedent's body to the appropriate burial place, and if the body is not transported to the appropriate burial place, Medicaid can pursue overpayment or collection.
The Department of Human Services may recover for payments made by the Death Payments Program from the Veteran's Administration (VA) or the estate of the decedent.
You certify the information you have provided on this application is true to the best of your knowledge.
If you intentionally make false statements on this application, you may be prosecuted under Hawaii Revised Statutes §346-43.5 or other criminal laws.
You further certify that the Death Payments Program payment shall be made to you and sent to your address as listed under Item II.
Sign on the Interested Party/Applicant's Signature line and enter the Date.
Sources
[1] DHS 1163 (Rev. 07/18), Death Payments Program Application, State of Hawaii Med-QUEST Division, Department of Human Services (the Official source link on this page).