Get Hi Dhs 204 2007-2026

The HI DHS 204 form is essential for submitting prescription drug claims under the Hawaii State Medicaid Fee for Service Program. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the HI DHS 204 form online.

1. Press the ‘Get Form’ button to access the form online and open it in your preferred editing tool.
2. Begin by entering the identification number in the designated field to ensure accurate tracking of your claim.
3. Fill in the recipient's name, ensuring correct spelling, followed by their date of birth for identification purposes.
4. Provide the pharmacy's National Provider Identifier (NPI) as well as the pharmacy's name and address to facilitate the processing of the claim.
5. Enter the prescriber's NPI and, if applicable, their DEA number for controlled substances (CII-V). This information is crucial for verifying the provider's credentials.
6. Indicate whether there is other drug or liability coverage by selecting 'Yes' or 'No.' If 'Yes,' specify the name of the coverage.
7. Document the date of the accident if applicable, along with the prescriber's name.
8. Specify whether the illness or injury is work-related, related to an automobile, or another type of accident by selecting the appropriate options.
9. For each medication, provide the required information including the RX number, metric quantity, billing unit (select Gm, ML, or Each), days supply, drug name/strength, DAW code, prior authorization number, and any diagnosis codes.
10. Verify that all fields are accurately filled out before submitting the form. Once completed, you can save changes, download, print, or share the form as needed.

Complete your documents online for a streamlined filing process.