Dhs 1169 Form – Fill Out and Use This PDF

The DHS 1169 form is a critical document used by the State of Hawaii's Med-QUEST Division, Department of Human Services. It is designed to collect necessary information from individuals or their authorized representatives about property ownership. This information is crucial for determining if a lien needs to be placed or maintained on a property when the owner receives medical assistance while living in a nursing facility or similar institution. Ready to secure your property's status? Click the button below to fill out the form.

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Dhs 1169 Form PDF Details

In navigating the complexities of healthcare benefits and legal obligations stemming from receiving medical assistance, the DHS 1169 form emerges as a crucial document for certain beneficiaries in Hawaii. Mandated by the Med-QUEST Division of the Department of Human Services, this form is integral for individuals who find themselves as inpatients in nursing facilities or other medical institutions and are recipients of medical assistance. Specifically, it addresses the state's requirement to place or maintain a lien on the home property of these beneficiaries to recoup medical assistance payments. However, it's important to note that such a lien does not compromise the individual's ownership or mandate the sale of the property but serves as a conditional claim that could be dissolved should the beneficiary be discharged and return home. The form is comprehensive, soliciting detailed information about property ownership, changes in residency of the property, and transactions that may affect the property's status, thereby ensuring that the state can accurately assess and implement the lien. It also caters to applicants who are unable to physically sign their names, accepting marks with the assurance that the act is both understood and voluntary. With sections designed for both the applicant/beneficiary or their authorized representative and the Department of Human Services, the DHS 1169 form embodies a critical process in the intersection of healthcare provision and property rights.

Question	Answer
Form Name	Dhs 1169 Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	medquest oahu application, medquest, medquest application, medquest oahu

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STATE OF HAWAII	Med-QUEST Division
Department of Human Services

MAINTENANCE OF LIEN STATUS

PART I (To be completed by the Applicant/Beneficiary or Authorized Representative)

The State is required to place a lien on the home property of certain individuals who receive medical assistance who is an inpatient in a nursing facility or other medical institution. An inpatient in a nursing facility can include a person receiving HCBS or residing in a CCFFH or E-ARCH. The information you give us will be used to determine if the State should place a lien on your home property or maintain the present lien on your home property. The lien will be for medical assistance payments made on your behalf. The lien will not affect your ownership in the property, nor will it require you sell the property. The lien may be dissolved if you are discharged from the medical institution and return to live in the home.

	 Female	 Male	 Married	 Divorced	 Widow	 Single

PRINT:	Last Name	First Name		M.I.	Date of Birth	Social Security Number

Name of Medical Institution					Date of Admission
						Check the appropriate box:
1a. Do you still own an interest in a house, condominium, apartment or other property that you
lived in before you were admitted to the nursing facility or medical institution?						 YES	 NO

1b. Do you still own a life interest or life estate, lease or leasehold interest in a house
condominium, apartment or other property?						 YES	 NO

1c. Do you still have a trust that owns a house, condominium, apartment or other property?
If “YES”, please provide a copy of the trust.						 YES	 NO
1d. Do you still have a Transfer on Death Deed (TODD)? If “YES”, please provide a copy of the						 YES	 NO
death deed (TODD).
2. If you no longer own an interest in your home, did you sell or transfer your interest in the
home?						 YES	 NO
2a. If SOLD:

	Buyers Name		Relationship to You		Date of Sale	Purchase Price
2b. If TRANSFERRED:

	Buyers Name		Relationship to You		Date of Sale	Purchase Price
3. Has anyone ceased living in your home in the past twelve (12) months? (If more space is						 YES	 NO
needed, please list this question number with their information on the back of this page.)						 YES	 NO


	Name		Relationship to You			Date Moved OUT
4. Has anyone moved into your home in the past twelve (12) months? (If more space is needed,						 YES	 NO
please list this question number with their information on the back of this page.)

	Name		Relationship to You			Date Moved IN

I HAVE READ OR HAD THIS DOCUMENT READ TO ME AND I UNDERSTAND ITS CONTENTS AND CERTIFY THAT I HAVE ANSWERED THE QUESTIONS TRUTHFULLY AND TO THE BEST OF MY KNOWLEDGE.

PRINT: Applicant/Beneficiary’s Name	Signature or Mark	Telephone #		Date

PRINT: Authorized Representative or Witness	Signature	Telephone#		Date

PRINT: Mailing Address of Authorized Representative or Witness		City	State	Zip Code
AUTHORIZED REPRESENTATIVE: DO YOU HAVE POWER OF ATTORNEY (POA)?		 YES  NO

IF “YES”, YOU MUST ATTACH A COPY OF POWER OF ATTORNEY OR GUARDIANSHIP DOCUMENT AND PROVIDE YOUR CURRENT MAILING ADDRESS. Note: Person witnessing an Applicant/Beneficiary’s mark “X” has determined to the best of the witness’ knowledge that the Applicant/Beneficiary is competent and understands his or her actions in signing this document. The use of an “X” is because the Applicant/Beneficiary cannot physically sign the document. (The witness must also sign this document and provide a mailing address.)

PART II (To be completed by DHS)

DOC:	Reason:
Case Number:			Date sent to MQD/FO
PRINT Worker’s Name:		Telephone	#:	Section/Unit:
DHS 1169A (Rev. 11/2020)		Page 1 of 1

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filling in hawaii medquest dhs1169 form part 1

Feel free to fill in the c Do you still have a trust that, YES NO, Buyers Name Relationship to You, Buyers Name Relationship to You, YES NO, Name Relationship to You Date, YES NO, Name Relationship to You Date, PRINT ApplicantBeneficiarys Name, PRINT Authorized Representative or, and PRINT Mailing Address of field with the demanded data.

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It is vital to record certain details inside the space PART II To be completed by DHS DOC, Reason, Date sent to MQDFO, Telephone Page of, and SectionUnit.

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