STATE OF HAWAII Department of Human Services Med-QUEST Division HEALTH SERVICES ADVISORY GROUP, INC. 1440 Kapiolani Blvd., Suite 1110 Honolulu, HI 96814 Phone: (808) 440-6000 Fax: (808) 440-6009 STATE.
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How to fill out the 1147 Form Hawaii online
Filling out the 1147 Form for Hawaii is an essential step in the Level of Care Evaluation process. This guide provides clear, step-by-step instructions to help individuals and their caregivers complete the form accurately and efficiently online.
Follow the steps to complete the form accurately
- Click ‘Get Form’ button to access the 1147 Form and open it for editing.
- In the first section, ensure to print or type your information clearly. Enter the patient's name in the format of Last, First, and Middle Initial.
- Provide the birthdate in the Month/Day/Year format, ensuring all information is accurate.
- Indicate the present address, specifying if it is the home address, CCFFH, or another type. Make sure to check the appropriate box.
- Select the patient's sex and complete the Medicare section by specifying if the patient has Part A or Part B coverage, including their ID number.
- Answer the Medicaid eligibility question, providing the ID number if applicable and the date of application.
- Fill in the attending physician or primary care provider's information, including their name, phone number, and fax number.
- Identify the service coordinator or contact person to whom the form should be returned, along with any relevant managed care plan information.
- Provide referral information and the assessment information completed by a registered nurse or physician.
- Select the desired level of care by checking the appropriate box and providing the relevant start and end dates.
- Fill in the length of the approval requested by checking one box to indicate your choice.
- Include additional comments if necessary, and complete any outstanding sections related to medical necessity or level of care determination.
- Review all information for accuracy, and ensure all required fields are filled out correctly.
- Once you have completed the form, save any changes made, and you may also choose to download, print, or share the document as needed.
Complete your documents online and submit the 1147 Form Hawaii for processing.
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