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Free Hawaii Dhs 1128 Template

The Hawaii DHS 1128 form is a crucial document used by the Med-Quest Division of the Department of Human Services to report disabilities. It requires detailed information about a patient’s physical and mental health conditions, treatment plans, and functional limitations. Completing this form accurately is essential for ensuring that individuals receive the necessary support and benefits related to their disabilities.

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Overview

The Hawaii DHS 1128 form is a critical document used by the Med-Quest Division of the Department of Human Services to assess disabilities for individuals seeking assistance. This form requires comprehensive information from licensed treating physicians or evaluators regarding a patient's medical history and current condition. It begins with the basic identification details of the patient, including their name, date of birth, and sex. The physician is then prompted to describe all significant physical and mental illnesses, injuries, or surgeries that relate to the patient's disability, ensuring that each condition is clearly documented with relevant dates. Additionally, the form asks for a list of current diagnoses, emphasizing the primary condition first, and outlines the treatment plan along with its expected duration. A crucial section focuses on the patient’s functional limitations in performing various types of work, which must be supported by medical evidence. The physician must also provide a statement regarding the expected duration of the disability, whether it is permanent or temporary, which plays a vital role in determining eligibility for services. Finally, the form includes a section for patient acknowledgment, ensuring that the individual is aware of the information being submitted. Completing this form accurately and thoroughly is essential for a smooth evaluation process, and any omissions may lead to delays or complications in receiving necessary support.

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STATE OF HAWAII	Med-Quest Division
Department of Human Services

DISABILITY REPORT

I. Name _________________________________ DOB: _____/_____/_____ Sex: _____

Last

First

Day

M/F

LICENSED TREATING PHYSICIAN/EVALUATOR: QUESTIONS MUST BE

ANSWERED COMPLETELY AND LEGIBLY OR FORM MAY BE RETURNED

II.Describe all significant physical and mental illnesses, accidents, deformities, injuries, illnesses and surgeries related to your patient’s disability. Specify date(s) applicable to condition(s) listed and attach copies of all related reports.

_________________________________________________________________________

III.Current diagnoses (List primary diagnosis first)

1._________________________________________________________________

2._________________________________________________________________

3._________________________________________________________________

4._________________________________________________________________

5._________________________________________________________________

6._________________________________________________________________

IV. Indicate your treatment plan and duration of treatment:

_________________________________________________________________________

V.Explain in detail your patient’s functional limitation(s) in doing medium and/or light (sedentary) work. Base your decision on medical evidence and not on subjective judgment. Attach copies of all medical evidence to this report.

_________________________________________________________________________

DHS 1128 (Rev. 11/09)

STATE OF HAWAII

Med-Quest Division

Department of Human Services

VI. LICENSED PHYSICIAN’S STATEMENT OF DISABILITY

Your patient’s disability is expected to be:

[

PERMANENT

AT LEAST 12 MONTHS, RE-EVALUATION NEEDED: _______________________

(MO/YR)

[] TEMPORARY TO: ______________________

		(MO/YR)
______________________________________________________			__________________________________________________
(Print/Type Name of Licensed Treating Physician/Evaluator)			(Signature of Licensed Treating Physician/Evaluator)
______________________________________________________			__________________________________________________
(Address)	(City)	(Zip Code)	(Phone No.)	(Date)
______________________________________________________			__________________________________________________
(Name of Health Plan)			(Medical Provider No. or NPI)
VII. PATIENT ACKNOWLEDGEMENT
______________________________________________________			__________________________________________________
(Print/Type Name of applicant/recipient)			(Patient Contact Number)
______________________________________________________			__________________________________________________
(Signature of applicant/recipient, Guardian or Representative)			(Date)

If Applicant/Recipient or Guardian or Representative do not sign, indicate reason: ____________

___________________________________________________________________________

FOR OFFICIAL USE ONLY
____________________________________	_______________________________
(Case Name)	(Case No.)
______________________________________________________	_________________________________________________
(Worker’s Name)	(Section Unit)
______________________________________________________	_________________________________________________
(Unit Address)	(Phone No.)	(Fax No.)

DHS 1128 (Rev. 11/09)

How to Fill Out Hawaii Dhs 1128

Once you have gathered the necessary information, filling out the Hawaii DHS 1128 form requires careful attention to detail. This form must be completed accurately to ensure that the information is processed efficiently. Below are the steps to guide you through the process of filling out the form.

Obtain the form: Download the Hawaii DHS 1128 form from the official website or request a physical copy from the appropriate office.
Fill in the patient’s information: In Section I, write the patient's name, date of birth, and sex. Ensure that the information is legible.
Identify the treating physician: In the same section, provide the name of the licensed treating physician or evaluator who is completing the form.
Describe medical history: In Section II, detail all significant physical and mental illnesses, accidents, deformities, injuries, and surgeries related to the patient’s disability. Include applicable dates and attach any relevant reports.
List current diagnoses: In Section III, list the current diagnoses, starting with the primary diagnosis. Include up to six diagnoses.
Outline the treatment plan: In Section IV, describe the treatment plan and the expected duration of treatment. Be as specific as possible.
Explain functional limitations: In Section V, provide a detailed explanation of the patient’s functional limitations in performing medium and/or light (sedentary) work. Use medical evidence to support your statements.
Complete the physician’s statement: In Section VI, indicate whether the patient’s disability is permanent or temporary, and provide the expected duration if temporary. Sign and print the physician's name, address, phone number, and medical provider number or NPI.
Patient acknowledgment: In Section VII, have the patient or their guardian sign and date the form. Include the patient’s contact number.
Review the form: Before submitting, double-check all entries for accuracy and completeness. Ensure that all required signatures are present.

After completing the form, submit it to the designated office as instructed. Keep a copy for your records. The processing of this form will follow, and any necessary follow-up will be communicated accordingly.

Common mistakes

When completing the Hawaii DHS 1128 form, individuals often overlook essential details, leading to potential delays in processing. One common mistake is failing to provide complete and legible information. The form explicitly states that questions must be answered thoroughly. Incomplete answers can result in the form being returned for clarification, prolonging the application process.

Another frequent error involves not specifying the dates related to significant medical conditions. The form requires applicants to describe illnesses, accidents, and surgeries with applicable dates. Omitting this information can hinder the assessment of the disability claim, as it is crucial for establishing the timeline of the patient's health issues.

Many applicants also neglect to attach relevant medical reports. The form requests copies of all medical evidence that supports the claims made in the report. Without these attachments, the evaluation may lack the necessary context, leading to potential denial of the claim.

In section III, listing current diagnoses is essential. However, some individuals fail to prioritize their primary diagnosis. Providing the primary diagnosis first is important for clarity. If the primary condition is not clearly stated, it may confuse the reviewer and impact the overall evaluation of the case.

Additionally, the treatment plan section is often inadequately filled out. Applicants may provide vague descriptions or fail to outline the duration of treatment. A clear and detailed treatment plan is vital for understanding the ongoing management of the patient's condition.

Applicants sometimes struggle with explaining functional limitations in section V. This section requires a detailed account of how the disability affects the individual's ability to perform work. Relying on subjective judgment instead of medical evidence can weaken the application. It is essential to provide objective information supported by medical documentation.

Another mistake involves not properly signing the form. The patient acknowledgment section requires the signature of the applicant or their representative. If this signature is missing, the form may be considered incomplete, resulting in further delays.

Lastly, individuals may fail to provide accurate contact information. The form requests the patient's contact number, which is crucial for follow-up communications. Incorrect or missing contact details can complicate the processing of the application and lead to unnecessary delays.

Documents used along the form

The Hawaii DHS 1128 form is a critical document used in the application process for disability benefits through the Med-Quest Division of the Department of Human Services. Along with this form, several other documents may be required to support a disability claim. Each of these documents serves a specific purpose and helps to provide a comprehensive view of the applicant's situation.

Hawaii DHS 1100 Form: This form is used to apply for Medicaid benefits. It collects essential information about the applicant’s financial status and household composition, which is crucial for determining eligibility.
Social Security Administration (SSA) Disability Report: This report gathers detailed information about the applicant's medical condition, work history, and daily activities. It plays a vital role in assessing the severity of the disability.
Medical Records: Documentation from healthcare providers detailing diagnoses, treatment plans, and progress notes. These records provide evidence of the applicant's medical condition and the impact it has on their ability to work.
Physician's Statement of Disability: A letter from a licensed physician that outlines the nature of the disability, treatment history, and prognosis. This statement is often required to validate the information provided in the DHS 1128 form.
Functional Capacity Evaluation (FCE): An assessment that evaluates an individual's physical and mental capabilities. This document helps to determine the extent of functional limitations and is often used to support disability claims.
Motorcycle Bill of Sale Form: To ensure proper documentation for your motorcycle transactions, refer to the helpful Motorcycle Bill of Sale details for a smooth and legally recognized transfer.
Work History Report: A detailed account of the applicant's employment history, including job titles, duties, and duration of employment. This report helps to establish how the disability affects the individual's ability to perform previous work.

Submitting these documents alongside the Hawaii DHS 1128 form can significantly enhance the chances of a successful disability claim. Each piece of information contributes to a clearer understanding of the applicant's circumstances, ensuring that the evaluation process is thorough and fair.

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Obtain Answers on Hawaii Dhs 1128

What is the Hawaii DHS 1128 form?

The Hawaii DHS 1128 form is a Disability Report used by the Med-Quest Division of the Department of Human Services. It helps document a patient's disabilities, including physical and mental conditions, to determine eligibility for assistance programs.

Who needs to fill out the DHS 1128 form?

This form must be completed by a licensed treating physician or evaluator who is familiar with the patient's medical history. The patient or their representative may also need to provide additional information or sign the form.

What information is required on the form?

The form requires detailed information, including:

Patient's name, date of birth, and sex.
A description of significant medical conditions, injuries, or surgeries.
Current diagnoses, listed in order of importance.
A treatment plan and expected duration.
An explanation of the patient's functional limitations related to work.

How should the form be submitted?

The completed form should be submitted to the appropriate Med-Quest office. It’s important to ensure all sections are filled out completely and legibly to avoid delays in processing.

What happens if the form is incomplete?

If the form is not filled out completely, it may be returned for additional information. This can delay the review process, so it's crucial to provide all required details upfront.

Is there a deadline for submitting the DHS 1128 form?

Can the patient or their representative fill out any part of the form?

The patient or their guardian can provide personal information and sign the acknowledgment section. However, the medical sections must be completed by the licensed treating physician or evaluator.

What should I do if I have questions about the form?

If you have questions about filling out the DHS 1128 form, you can contact the Med-Quest Division directly. They can provide guidance and clarify any concerns you may have.

Document Attributes

Fact Name	Description
Form Purpose	The DHS 1128 form is used to report disabilities for individuals applying for Med-Quest services in Hawaii.
Governing Law	This form is governed by the Hawaii Revised Statutes, specifically under Chapter 346, which pertains to public welfare.
Patient Information	Patients must provide their full name, date of birth, and sex to ensure accurate identification.
Treatment Provider	A licensed treating physician or evaluator must complete the form, ensuring that all questions are answered legibly.
Condition Details	Providers must describe all significant physical and mental conditions related to the patient's disability, including dates and relevant reports.
Current Diagnoses	Physicians are required to list the patient's current diagnoses, prioritizing the primary diagnosis.
Treatment Plan	The form requires a detailed treatment plan, including the expected duration of treatment for the patient's disability.
Functional Limitations	Physicians must explain the patient’s functional limitations in performing medium and light work, based on medical evidence.
Disability Expectation	The form allows the physician to indicate whether the disability is permanent or temporary, along with the expected duration.

Misconceptions

The DHS 1128 form is an essential document for individuals seeking disability benefits in Hawaii. However, several misconceptions surround its purpose and requirements. Here are eight common misunderstandings:

The form is only for physical disabilities. Many believe that the DHS 1128 form is limited to physical conditions. In reality, it encompasses both physical and mental disabilities, allowing for a comprehensive evaluation of an individual's health.
Only doctors can fill out the form. While licensed treating physicians are required to complete the form, other qualified evaluators can also provide the necessary information. This includes psychologists and other healthcare professionals who are familiar with the patient's condition.
Submitting the form guarantees approval for benefits. Completing and submitting the DHS 1128 does not automatically mean benefits will be granted. The information provided is just one part of a broader assessment process that includes reviewing medical evidence and other documentation.
All questions must be answered in detail. Some may think that every question requires extensive detail. While thoroughness is important, the form should be filled out legibly and completely. Key information about the patient’s condition and limitations is what matters most.
Medical evidence is optional. A common misconception is that attaching medical evidence is not necessary. In fact, providing supporting documentation is crucial. The form explicitly states that medical evidence must accompany the report to substantiate the claims made.
The form can be submitted without a signature. Some individuals believe that they can submit the DHS 1128 without a signature from the licensed physician. However, the form requires the physician's signature to validate the information provided and confirm their professional assessment.
Only recent medical conditions need to be reported. There is a belief that only current conditions are relevant. However, the form asks for a comprehensive history of significant illnesses, accidents, and surgeries that relate to the patient's disability, regardless of when they occurred.
Once submitted, the form cannot be updated. Many assume that once the DHS 1128 is submitted, it cannot be modified. In fact, applicants can provide updates or additional information if their medical condition changes or if further evidence becomes available.

Understanding these misconceptions can help individuals navigate the process more effectively and ensure that their applications are completed accurately and thoroughly.

Key takeaways

When filling out the Hawaii DHS 1128 form, several important considerations come into play to ensure that the process runs smoothly and efficiently. Here are key takeaways to keep in mind:

Complete Information: It is essential to answer all questions completely and legibly. Incomplete forms may be returned, causing delays in processing.
Detail Medical History: Provide a thorough description of all significant physical and mental illnesses, injuries, and surgeries. Include dates and attach relevant medical reports to support the information provided.
Current Diagnoses: List the patient's current diagnoses, starting with the primary condition. This helps to clarify the patient's health status for evaluation purposes.
Treatment Plan: Clearly indicate the treatment plan and the expected duration of treatment. This information is crucial for understanding the patient's ongoing care needs.
Functional Limitations: Describe in detail any functional limitations the patient faces when attempting to perform medium or light work. Base these descriptions on medical evidence rather than personal opinions.
Physician’s Statement: Ensure that the licensed physician's statement of disability is filled out accurately. This includes specifying whether the disability is permanent or temporary, as well as providing the physician's contact information.

By adhering to these guidelines, individuals can facilitate a more efficient review process and improve the likelihood of a favorable outcome for their disability claims.