Get 1147 Form

The 1147 Form is an important document used in the State of Hawaii for the evaluation of individuals seeking long-term care or hospice services through the Med-Quest Division. This guide provides a step-by-step process to help you complete the form online effectively.

Follow the steps to fill out the 1147 Form online

1. Press the ‘Get Form’ button to access the 1147 Form and open it in your preferred online document editor.
2. Begin filling out the applicant or client name in the designated field, ensuring you provide the full legal name as it appears on official documents.
3. Enter the date of birth in the format of month/day/year to ensure accuracy.
4. Input the DHS case number and DHS client number accurately, as these numbers are crucial for the processing of your application.
5. Select the type of referral by checking the appropriate box, either 'ADRC Initial Determination' or 'ADRC Redetermination'. Include the date of the last ADRC completed.
6. Fill in the referral source, including the relevant division, section, or unit within DHS, along with the name and contact details of the eligibility worker.
7. Include the name of the QUEST health plan and provide the contact information of a person who can be reached for further inquiries.
8. If applicable, submit any required supporting documents, including the DHS 1127, DHS 1128, or additional information from the QUEST health plan or medical provider.
9. Review all entries for accuracy and completeness before proceeding to the final steps.
10. Once all information is confirmed, you can save your changes, download a copy of the form for your records, print it for physical submission, or share it electronically as needed.

Start filling out your 1147 Form online today for prompt processing.