Hawaii Form DHS 1128 – Fill Out and Use This PDF

Hawaii Form DHS 1128 is an important document for those living in the state. Required by the Hawaii Department of Human Services to register with local Care System Networks (CSNs), individuals will be asked for their DHS 1128 when enrolling for benefits and securing services. With a Hawaii Form DHS 1128, paperwork can be processed efficiently to provide ongoing support throughout the islands with service such as housing, healthcare, transportation and more. Collecting all relevant information from one central place makes it easy to get the necessary aid without being required to submit multiple applications or forms. Ensuring compliance with guidelines and qualifications, the DHS 1128 fits critical functions in providing quality solutions while conserving resources and improving accuracy overall.

Get Form Now Download PDF

Hawaii Form DHS 1128 PDF Details

Are you considering opening a business in the Hawaiian Islands? If so, you will need to understand and comply with all applicable laws from both Hawaii’s state government and federal agencies. One of these requirements is completing form DHS 1128, which is an application for state licensure to do business within the State of Hawaii. In this blog post, we’ll provide a comprehensive overview of what you need to know about filling out and filing DHS 1128 for your Hawaiian-based business.

Question	Answer
Form Name	Hawaii Form DHS 1128
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	dhs 1128, dhs forms hawaii, 1148 form, medquest form 1128

Form Preview Example

STATE OF HAWAII	Med-Quest Division
Department of Human Services

DISABILITY REPORT

I. Name _________________________________ DOB: _____/_____/_____ Sex: _____

Last

First

Day

M/F

LICENSED TREATING PHYSICIAN/EVALUATOR: QUESTIONS MUST BE

ANSWERED COMPLETELY AND LEGIBLY OR FORM MAY BE RETURNED

II.Describe all significant physical and mental illnesses, accidents, deformities, injuries, illnesses and surgeries related to your patient’s disability. Specify date(s) applicable to condition(s) listed and attach copies of all related reports.

_________________________________________________________________________

III.Current diagnoses (List primary diagnosis first)

1._________________________________________________________________

2._________________________________________________________________

3._________________________________________________________________

4._________________________________________________________________

5._________________________________________________________________

6._________________________________________________________________

IV. Indicate your treatment plan and duration of treatment:

_________________________________________________________________________

V.Explain in detail your patient’s functional limitation(s) in doing medium and/or light (sedentary) work. Base your decision on medical evidence and not on subjective judgment. Attach copies of all medical evidence to this report.

_________________________________________________________________________

DHS 1128 (Rev. 11/09)

STATE OF HAWAII

Med-Quest Division

Department of Human Services

VI. LICENSED PHYSICIAN’S STATEMENT OF DISABILITY

Your patient’s disability is expected to be:

[

PERMANENT

AT LEAST 12 MONTHS, RE-EVALUATION NEEDED: _______________________

(MO/YR)

[] TEMPORARY TO: ______________________

		(MO/YR)
______________________________________________________			__________________________________________________
(Print/Type Name of Licensed Treating Physician/Evaluator)			(Signature of Licensed Treating Physician/Evaluator)
______________________________________________________			__________________________________________________
(Address)	(City)	(Zip Code)	(Phone No.)	(Date)
______________________________________________________			__________________________________________________
(Name of Health Plan)			(Medical Provider No. or NPI)
VII. PATIENT ACKNOWLEDGEMENT
______________________________________________________			__________________________________________________
(Print/Type Name of applicant/recipient)			(Patient Contact Number)
______________________________________________________			__________________________________________________
(Signature of applicant/recipient, Guardian or Representative)			(Date)

If Applicant/Recipient or Guardian or Representative do not sign, indicate reason: ____________

___________________________________________________________________________

FOR OFFICIAL USE ONLY
____________________________________	_______________________________
(Case Name)	(Case No.)
______________________________________________________	_________________________________________________
(Worker’s Name)	(Section Unit)
______________________________________________________	_________________________________________________
(Unit Address)	(Phone No.)	(Fax No.)

DHS 1128 (Rev. 11/09)

How to Edit Hawaii Form DHS 1128 Online for Free

Working with PDF forms online is a breeze with this PDF tool. You can fill in hawaii dhs 1128 here effortlessly. In order to make our editor better and simpler to work with, we consistently come up with new features, taking into consideration feedback from our users. It merely requires several easy steps:

Step 1: Press the "Get Form" button in the top area of this webpage to get into our tool.

Step 2: With this online PDF editing tool, you're able to accomplish more than merely fill in blank fields. Express yourself and make your forms appear perfect with custom text incorporated, or adjust the original input to perfection - all comes with an ability to incorporate your own photos and sign the PDF off.

This PDF will need particular info to be entered, thus be sure you take whatever time to fill in exactly what is asked:

1. Start completing your hawaii dhs 1128 with a selection of major blank fields. Get all the required information and make sure nothing is forgotten!

2. Once your current task is complete, take the next step – fill out all of these fields - Indicate your treatment plan and, V Explain in detail your patients, Base your decision on medical, and DHS Rev with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

dhs1128 quest completion process clarified (stage 2)

Concerning Base your decision on medical and DHS Rev, be certain you double-check them in this section. These two are certainly the key ones in this page.

3. The following portion focuses on Your patients disability is, PERMANENT, AT LEAST MONTHS REEVALUATION, TEMPORARY TO, MOYR, PrintType Name of Licensed, Signature of Licensed Treating, Address, City, Zip Code, Phone No, Date, Name of Health Plan, Medical Provider No or NPI, and VII PATIENT ACKNOWLEDGEMENT - type in all these blanks.

4. To go forward, this part requires filling in a couple of blanks. Included in these are Case Name, Case No, Workers Name, Section Unit, Unit Address, Phone No, Fax No, and DHS Rev, which are essential to continuing with this form.

dhs1128 quest completion process detailed (part 4)

Step 3: Reread what you have inserted in the blanks and hit the "Done" button. Get hold of your hawaii dhs 1128 the instant you subscribe to a free trial. Easily access the pdf form from your FormsPal cabinet, together with any modifications and adjustments all synced! FormsPal guarantees protected form tools devoid of data recording or sharing. Be assured that your data is safe with us!

Hawaii Form DHS 1128 – Fill Out and Use This PDF

Hawaii Form DHS 1128 PDF Details

Form Preview Example

How to Edit Hawaii Form DHS 1128 Online for Free

Hawaii Form DHS 1128 isn’t the one you’re looking for?

Related Documents