Dhs Form 1109 PDF Details

In navigating the complexities of applying for medical assistance in the State of Hawaii, individuals encounter various forms, with the DHS 1109 form being particularly noteworthy. Issued by the Department of Human Services, Med-QUEST Division, this document acts as a crucial step in the application process for those seeking government-assisted healthcare benefits. The form is designed to notify applicants when additional information is required to proceed with their medical assistance application, emphasizing the importance of submitting the necessary documentation within a ten-day timeframe to avoid denial or discontinuation of benefits. Applicants are instructed to provide copies of documents verifying U.S. citizenship or alien status, photo identification, income and asset statements, other health insurance cards, as well as unpaid medical bills or estimates. Additionally, the form requests completion, signing, and return of certain forms, alongside the applicant's Social Security number or application for a number. This structured approach, supported by the legal framework outlined in various sections of the Hawaii Administrative Rules, seeks to streamline the eligibility determination process, ensuring that the needs of applicants are addressed promptly and accurately. Moreover, the DHS 1109 form facilitates communication between applicants and eligibility workers, thereby enhancing the efficiency of the Med-QUEST Division in assisting Hawaii’s residents. The integration of a notice for those requiring interpreter services underscores the division's commitment to accessibility and inclusivity in providing medical assistance.

QuestionAnswer
Form NameDhs Form 1109
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesinterpreter, mdhhs pub 1160, form 1109, hawaii dhs 1109 printable

Form Preview Example

State of Hawaii

Med-QUEST Division

Department of Human Services

 

Medical Assistance Application: Need More Information

Ten-Day Pending Notice

Name

________________________________________

Today’s Date

________________

Address

________________________________________

Case Number

________________

City, State, and Zip Code _____________________________________________________________

We need more information to process your form. Please return this paper with COPIES of items marked ( ) below. Your medical assistance benefits may be denied or stopped if we do not receive them by the due date.

Due Date ______________________

You can mail, fax, or bring the document copies to the Med-QUEST office. If you need a free interpreter, have questions about this notice, or there is a problem with the document copies, please contact the eligibility worker listed below.

U.S. Citizenship

_____________________________________________________.

Alien Status

_____________________________________________________.

Photo Identification

_____________________________________________________.

Income Statements

_____________________________________________________.

Asset Statements

_____________________________________________________.

Other Health Insurance Card

_____________________________________________________.

Unpaid Medical Bills or Estimate

_____________________________________________________.

Complete, Sign, and Return Forms _____________________________________________________.

Social Security Number or

_____________________________________________________.

Application for a Number

 

Other

 

Thank you for your cooperation and we look forward to helping you!

Authorization: H.A.R. 17-1705-7, 17-1705-10, 17-1711-6; 17-1711-7, 17-1711-9, 17-1711-12, 17-1711-13, 17-1713-4; __________________________________________________________________________.

Eligibility Worker Name ________________________________

Phone Number ________________

DHS 1109 (12/09)

How to Edit Dhs Form 1109 Online for Free

You could complete eligibility effortlessly by using our PDF editor online. The editor is constantly upgraded by us, acquiring awesome functions and growing to be much more convenient. With some basic steps, it is possible to start your PDF editing:

Step 1: First of all, open the tool by clicking the "Get Form Button" in the top section of this webpage.

Step 2: With the help of this online PDF editor, it is possible to do more than merely complete forms. Try all of the functions and make your forms appear perfect with custom text added in, or fine-tune the original content to excellence - all that comes with an ability to incorporate stunning pictures and sign the file off.

As for the blanks of this specific form, here is what you need to know:

1. Whenever filling in the eligibility, make sure to include all necessary blanks within its associated part. This will help to facilitate the process, which allows your information to be handled quickly and accurately.

Citizenship completion process outlined (step 1)

2. Now that this segment is completed, it is time to add the essential specifics in cid Income Statements, cid Asset Statements, cid Other Health Insurance Card, cid Unpaid Medical Bills or, cid Complete Sign and Return Forms, cid Social Security Number or, cid Other, and Thank you for your cooperation and so you can progress further.

cid Unpaid Medical Bills or, cid Other Health Insurance Card, and cid Complete Sign and Return Forms inside Citizenship

People often make errors when completing cid Unpaid Medical Bills or in this area. Ensure you read again what you type in right here.

3. This next part is rather uncomplicated, Thank you for your cooperation and, and DHS - all of these form fields will have to be filled out here.

DHS, Thank you for your cooperation and, and DHS of Citizenship

Step 3: Make certain the details are correct and click on "Done" to continue further. Go for a free trial option with us and gain instant access to eligibility - download or edit from your FormsPal cabinet. FormsPal is dedicated to the privacy of all our users; we make sure that all information going through our system is kept secure.