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Get Hi Dhs 1139a 2013-2025
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How to fill out the HI DHS 1139A online
The HI DHS 1139A form is an essential document for psychiatry and psychology credentialing in Hawaii. This guide will help you navigate the online filling process seamlessly.
Follow the steps to complete the HI DHS 1139A form online.
- Click 'Get Form' button to access the HI DHS 1139A and open it for editing.
- Begin by entering your name in the designated fields for first, middle, and last names. Ensure accuracy as this information is crucial for identification.
- Provide your business address. Fill in the necessary details including the street number, street name, suite number (if applicable), city, state/country, and zip code.
- Complete the section regarding your place of birth. It is important for demographic and identification purposes.
- Enter your telephone number to ensure that the reviewing authority can contact you if needed.
- Input your birth date in the specified format (month/day/year). Double-check the format to avoid any errors.
- Indicate whether you are a resident of Hawaii by selecting 'Yes' or 'No.' If 'Yes,' note how long you have been a resident.
- Provide information regarding your medical/psychology certification or licensing in other states. Indicate if you have been denied a certificate or if any license has been suspended or revoked.
- Fill out the education and experience sections accordingly. List the institutions and employers in reverse chronological order, including your major course of study, graduation dates, and duties performed.
- Indicate your status regarding the American Board of Examiners in Professional Psychiatry and Neurology and any affiliations with hospitals or clinics.
- Finally, review all entered information for accuracy, then provide your signature and date signed at the bottom of the form.
- Once all fields are completed, save your changes, download a copy for your records, and be prepared to print or share the form as necessary.
Take the next step in your credentialing process by completing the HI DHS 1139A form online today.
To qualify for Medicaid Quest in Hawaii, individuals must meet specific income and eligibility requirements set by the state. Generally, these requirements assess both income levels and family size, ensuring proper access to healthcare services. For the most current qualifications and guidelines, visiting the HI DHS 1139A can provide you with accurate and detailed information. Understanding these criteria can help you or your loved ones gain crucial healthcare assistance.
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