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Get Hi Dhs 1139b 2013-2026
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How to fill out the HI DHS 1139B online
Filling out the HI DHS 1139B form online can be straightforward with the right guidance. This form is essential for certifying agreement regarding non-emergency ground transportation services within Hawaii's Med-QUEST program.
Follow the steps to successfully complete the HI DHS 1139B form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In Part A, enter the name of the provider or authorized business agent who will be delivering transportation services. Ensure all names are spelled correctly for verification purposes.
- Review the certification statement carefully, confirming that you understand the implications of using Federal and State funds for payments. This ensures compliance with applicable regulations.
- Sign the form in the designated signature field, affirming your agreement to the conditions outlined in the document. It is essential to use an electronic signature if provided by the editing system.
- Enter the date of signing in the provided space. This confirms when the agreement was executed.
- After completing the form, review all entered information for accuracy. Ensure that no fields are left blank that should be filled.
- Finally, save your changes, download the form for your records, and consider printing it for submission or sharing with relevant parties as required.
Complete the HI DHS 1139B form online today to ensure your compliance with transportation service requirements.
For assistance regarding Hawaii Medicaid services, including information on HI DHS 1139B, you can reach out to their customer service. They provide a dedicated phone number for inquiries. Having direct communication with the provider can help clarify any coverage questions you might have.