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INSTRUCTIONS
DHS 1131 (Rev. 06/14)
MEDICAL ASSISTANCE REFERRAL FORM
FOR THE COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCERPURPOSE:
DHS 1131 is a form used by the Hawaii Breast and Cervical
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How to fill out dhs 1131 referral form
How to fill out dhs 1131 referral form
01
To fill out the DHS 1131 referral form, follow these steps:
02
Start by entering the date of referral in the specified field.
03
Fill out the personal information section with the client's name, address, phone number, and other relevant details.
04
Provide information about the referring agency or individual in the designated fields.
05
Specify the reason for referral and provide any supporting documentation if required.
06
Enter details about the client's demographics, such as age, gender, and ethnicity.
07
Indicate the client's preferred language and any language services required.
08
Provide information about the client's insurance coverage, if applicable.
09
If the referral is related to a specific program or service, provide the necessary details.
10
Finally, review the completed form for accuracy and ensure all required fields are filled out.
11
Submit the form as per the instructions provided by the referral agency or organization.
Who needs dhs 1131 referral form?
01
The DHS 1131 referral form is typically needed by individuals or agencies who are referring clients to the Department of Human Services (DHS) for various programs or services. This form may be required by social workers, healthcare professionals, counselors, community organizations, or any other entity involved in connecting individuals in need with government assistance or support.
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What is dhs 1131 referral form?
The DHS 1131 referral form is a document used for reporting concerns of abuse, neglect, or exploitation of vulnerable individuals to the Department of Human Services.
Who is required to file dhs 1131 referral form?
Anyone who suspects or witnesses abuse, neglect, or exploitation of vulnerable individuals is required to file the DHS 1131 referral form.
How to fill out dhs 1131 referral form?
The DHS 1131 referral form can be filled out by providing details of the situation, the individuals involved, and any supporting evidence. The form can then be submitted to the Department of Human Services for review.
What is the purpose of dhs 1131 referral form?
The purpose of the DHS 1131 referral form is to raise awareness and report instances of abuse, neglect, or exploitation of vulnerable individuals, and to ensure appropriate intervention and protection measures are taken.
What information must be reported on dhs 1131 referral form?
The DHS 1131 referral form must include details of the situation, the individuals involved, any evidence or witnesses, and contact information of the reporter.
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