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Get HI DHS 1147 2014-2024

C. 1440 Kapiolani Blvd., Suite 1110 Honolulu, HI 96814 Phone: (808) 440-6000 Fax: (808) 440-6009 STATE OF HAWAII Level of Care (LOC) and At Risk Evaluation 1. PLEASE PRINT OR TYPE  Initial Request 2. PATIENT NAME (Last, First, M.I.)  Annual Review 3. BIRTHDATE Month/Day/Year 4. SEX  Reconsideration  Other review 5. MEDICARE Part A  Yes  No Part B  Yes  No ID#:___________________ 6. MEDICAID ELIGIBLE?  Yes ID # _______________________  No Date Applied ______.

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