Get Hi Dhs 1149 2013-2026
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How to fill out the HI DHS 1149 online
The HI DHS 1149 form is a critical document that facilitates the emergency processing of applications for medical assistance under the Med-QUEST Division of the State of Hawaii. This guide provides comprehensive, step-by-step instructions for completing the form online, ensuring that you can help individuals in need of urgent medical services.
Follow the steps to accurately complete the HI DHS 1149 form.
- Click ‘Get Form’ button to access the HI DHS 1149 and open it in the editor.
- In the first field, enter the patient's legal name, providing their first, middle, and last name as required.
- Next, fill in the patient's birth date in the format of month, day, and year.
- Provide the patient's social security number in the designated field.
- Enter the date on which the application form DHS 1100 or DHS 1100A was submitted to Med-QUEST, also using month, day, and year format.
- Detail the medical services required, indicating the diagnosis necessitating emergency medical services.
- Select the appropriate checkboxes that correspond to the potential consequences if treatment does not begin within 48 hours or 2 business days.
- List the treatments, medications, and/or medical supplies that the patient requires immediately, clarifying that they are unavailable without health insurance.
- The physician must then certify that the form has been completed truthfully, indicating this by providing their signature.
- Finally, fill in the physician’s address, printed name, phone number, fax number, and the date of signing.
- After ensuring all fields are correctly filled, save changes. You may then download, print, or share the completed form as needed.
Complete and submit your forms online today to ensure prompt assistance for those in need.
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The income limit for Medicaid in Hawaii is set at about 138% of the federal poverty guidelines. For a single person, this translates to an income cap of around $18,754 per year. If your income falls below this threshold, you may be eligible for assistance covered under HI DHS 1149, providing essential healthcare services.
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