Hawaii Form DHS 1128 – Fill Out and Use This PDF

The Hawaii DHS 1128 form is an essential document used by the State of Hawaii's Med-Quest Division, Department of Human Services, to report and assess an individual's disabilities. This detailed form requires information on the patient's significant physical and mental illnesses, accidents, or injuries that contribute to their disability, making it a critical component in the process of determining eligibility for disability benefits. To ensure thorough evaluation, the form also solicits a licensed physician’s statement on the patient’s disability, current diagnoses, treatment plans, and the expected duration of the disability, alongside an acknowledgment from the patient or their representative.

For those in need of assistance with their disability claims, completing the Hawaii DHS 1128 form accurately is a vital step. Click the button below to learn more about filling out the form correctly.

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Hawaii Form DHS 1128 PDF Details

In the State of Hawaii, individuals applying for disability benefits through the Med-Quest Division of the Department of Human Services are required to complete the DHS 1128 form, a critical document in the evaluation and determination of disability claims. This Disability Report demands a comprehensive outline of an applicant's physical and mental health conditions, including detailed accounts of illnesses, accidents, deformities, injuries, and surgeries, alongside a requirement for attaching pertinent medical reports. It further necessitates the licensed treating physician or evaluator to list current diagnoses, with a primary diagnosis taking precedence, and to elucidate the treatment plan envisaged for the applicant, including the duration. Significantly, the form requires a meticulous description of the patient's functional limitations in performing medium to light, or sedentary, work, emphasizing the importance of basing these evaluations on medical evidence, thereby avoiding subjective judgments. Another key component of the DHS 1128 form is the licensed physician’s statement of disability, which categorizes the disability as either permanent, with an acknowledgment of the need for re-evaluation at a stated future date, or temporary, with a specified end date. Additionally, this form includes sections for patient acknowledgment, necessitating signatures from the applicant or their guardian or representative, thereby affirming the accuracy and completeness of the information provided. All these facets of the DHS 1128 form underscore its significance in facilitating a thorough and judicious review process for disability claims within Hawaii, ensuring that decisions are grounded in detailed and verifiable medical assessments.

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

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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)

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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)

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Hawaii Form DHS 1128 – Fill Out and Use This PDF

Hawaii Form DHS 1128 PDF Details

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