Get 1147 Form 2020-2025

The 1147 Form is a crucial document for assessing the level of care needed for individuals in Hawaii. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring a smooth and efficient process for users.

Follow the steps to fill out the 1147 Form online

1. Click the ‘Get Form’ button to access the 1147 Form. This action allows you to download and open the form in an editable format.
2. Fill in the patient's name in the section provided, ensuring to use the last name followed by the first name and middle initial as required.
3. Enter the patient's birthdate in the Month/Day/Year format. Double-check for any errors to ensure accuracy.
4. Indicate the present address of the patient by selecting the appropriate option: Home, CCFFH, or Other. If 'Other' is selected, specify the address.
5. Mark the patient's sex in the designated section provided.
6. Respond to the Medicare questions by checking 'Yes' or 'No' for Part A and Part B. Provide the relevant ID number where applicable.
7. Indicate Medicaid eligibility by checking 'Yes' or 'No', and enter the corresponding ID number or date applied as needed.
8. Provide the Medicaid provider number if applicable, along with the attending physician or primary care provider's full name and contact details.
9. Specify the return methods for the form by completing the contact information fields such as phone, fax, and email where the form should be sent.
10. Complete the referral and assessment sections as instructed, making sure to fill in all necessary details regarding the responsible person and their relationship to the patient.
11. Select the requesting level of care by checking one box that represents the service required. Also, fill in the level of care begin and end dates along with the length of approval requested.
12. Review all filled information for accuracy and completeness before saving the changes, downloading, printing, or sharing the completed form as necessary.

Take action now and complete the 1147 Form online to ensure timely assistance.