HI DHS 1139C 2013-2025 free printable template

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STATE OF HAWAII Department Of Human Services Request Division Health Care Services Branch P.O. Box 700190 Cupola, Hawaii 967090190 HOME HEALTH SERVICES ATTACHMENT Scope of Services The PROVIDER shall

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How to fill out HI DHS 1139C

01

Obtain the HI DHS 1139C form from the appropriate Hawaii Department of Human Services website or office.

02

Fill in your personal information at the top of the form, including your name, address, and contact information.

03

Specify the type of assistance you are applying for in the designated section.

04

Provide any required supporting documentation as outlined in the instructions.

05

Carefully review all entries for accuracy and completeness.

06

Sign and date the form at the bottom to certify the information provided.

07

Submit the form as directed, either online, by mail, or in person.

Who needs HI DHS 1139C?

01

Individuals or families in Hawaii seeking financial assistance or support services from the Department of Human Services.

02

Those applying for benefits such as Temporary Assistance for Needy Families (TANF) or other state assistance programs.

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What is HI DHS 1139C?

HI DHS 1139C is a form used by the Department of Human Services in Hawaii for reporting and documenting specific health and safety information related to care facilities.

Who is required to file HI DHS 1139C?

Care facilities and providers that fall under the jurisdiction of the Hawaii Department of Human Services are required to file HI DHS 1139C.

How to fill out HI DHS 1139C?

To fill out HI DHS 1139C, users should follow the provided instructions carefully, entering required information such as facility details, service types, and staff credentials where indicated.

What is the purpose of HI DHS 1139C?

The purpose of HI DHS 1139C is to ensure compliance with health and safety regulations, providing a standardized way to report necessary information about care facilities.

What information must be reported on HI DHS 1139C?

Information to be reported on HI DHS 1139C typically includes facility name, address, services provided, staffing information, and any relevant incidents or compliance issues.

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