Get Hi Dhs 1125a 2004-2026

Navigating the HI DHS 1125A form can seem challenging, but with our step-by-step guide, you will find the process straightforward and manageable. This form is crucial for documenting the details surrounding an accident and ensuring proper medical coverage.

Follow the steps to successfully complete the HI DHS 1125A form online.

1. Click ‘Get Form’ button to access and open the HI DHS 1125A online in your editor.
2. In the first section, enter the name of the injured person, including last name, first name, and middle initial. Be sure to include their identification number and case number in the appropriate fields.
3. Provide the injured party's address, social security number, and case name if it differs from the name entered above. Include their date of birth and sex in the designated fields.
4. Select the type of accident from the options provided, such as auto, moped, motorcycle, pedestrian, bicycle, worker’s compensation, assault, or other. Make sure to tick the appropriate box that describes the accident.
5. Enter the date of the accident, application date, and medical eligibility date in the following fields.
6. Indicate the medical coverage by selecting the appropriate option such as Medicaid Fee for Service, QUEST Plan, or other hospitalization and medical insurance.
7. In the next field, provide a detailed description of how the accident occurred, including the actual time and location.
8. Describe the type of injury sustained in the accident, providing examples such as broken arm, head injury, etc. Use Section 19 for additional space if necessary.
9. Indicate the extent of the injury by describing it as serious, slightly, etc.
10. List the names of healthcare providers who treated the recipient, including doctors, hospitals, laboratories, etc.
11. Specify whether the recipient is still under medical care for their injury by selecting yes or no.
12. Provide information about any person or property owner who may be at fault, including their insurance company and policy number.
13. Indicate if the recipient intends to file a suit by selecting yes or no.
14. If applicable, enter the date of settlement.
15. Specify if the recipient has an attorney by selecting yes or no. If yes, provide the attorney's name, address, and contact number.
16. Indicate the type of no-fault insurance the recipient had at the time of the accident by selecting the appropriate box and providing additional insurance information as needed.
17. Clarify the role of the recipient in the accident by selecting if they were a driver or passenger in their own vehicle or in another vehicle.
18. Indicate whether a police report was filed by selecting yes or no. If yes, provide the report number and details regarding the vehicle owner and driver.
19. Use the blank sheet for any additional information that may not be captured in the previous fields.
20. Finally, fill in the worker’s name, date, section/unit, and phone number as required.
21. Once all sections are completed, ensure to save any changes made, download the form for your records, or print it out for submission.

Complete your HI DHS 1125A form online today to ensure a smooth processing of your medical claims.