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Get HI DHS 1149 2013-2024

I acknowledge improper use of this form may result in the withholding of payment from Medicaid and that this completed form is subject to evaluation by the Physician s Signature Physician s Address DHS 1149 Rev. 09/13 Physician s Printed Name Phone Number Date Fax Number. State of Hawaii Department of Human Services Med-QUEST Division REQUEST for APPLICATION EMERGENCY PROCESSING This form should be completed and signed by a physician if the patient has an emergent condition that will not be treated without health insurance. Completion of this form does not guarantee medical assistance eligibility. Patient s Legal Name First Middle and Last Name Patient s Birth Date Month Day and Year Patient s Social Security Number Date application form DHS1100 or DHS 1100A submitted to Med-QUEST Month Day and Year This patient requires emergency medical services based on the following diagnosis Treatment must start within 48 hours or 2 business days from the date the physician signs this form or the patient s medical condition could result in check appropriate boxes Serious risk of disease Serious health complications Irreparable harm or Threat to life or vital function Treatments medications and/or medical supplies that are needed immediately and are not available to the patient without health insurance I certify the information I provided on this form is true to the best of my knowledge as a physician and is not being completed for a patient with a non-emergent condition to obtain immediate application processing for Medicaid coverage. State of Hawaii Department of Human Services Med-QUEST Division REQUEST for APPLICATION EMERGENCY PROCESSING This form should be completed and signed by a physician if the patient has an emergent condition that will not be treated without health insurance. Completion of this form does not guarantee medical assistance eligibility. Patient s Legal Name First Middle and Last Name Patient s Birth Date Month Day and Year Patient s Social Security Number Date application form DHS1100 or DHS 1100A submitted to Med-QUEST Month Day and Year This patient requires emergency medical services based on the following diagnosis Treatment must start within 48 hours or 2 business days from the date the physician signs this form or the patient s medical condition could result in check appropriate boxes Serious risk of disease Serious health complications Irreparable harm or Threat to life or vital function Treatments medications and/or medical supplies that are needed immediately and are not available to the patient without health insurance I certify the information I provided on this form is true to the best of my knowledge as a physician and is not being completed for a patient with a non-emergent condition to obtain immediate application processing for Medicaid coverage. .

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Keywords relevant to HI DHS 1149

  • certify
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  • medicaid
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  • withholding
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