HI DHS 1139D 2013-2025 free printable template
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Acute Hospital Attachment Form (DHS 1139D). Nursing ... on the Med-QUEST Division website at www.med-quest.us. If you have ... Hawaii State Medicaid Program Provider of Service Information Form (DHS
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How to fill out HI DHS 1139D
01
Obtain the HI DHS 1139D form from the relevant agency or website.
02
Read the instructions provided on the form carefully.
03
Fill out the personal identification section with your name, address, and contact information.
04
Provide any required information about your financial situation in the income section.
05
Complete the section regarding your household composition, listing all members.
06
Attach any necessary documentation, such as proof of income or residency.
07
Review the form thoroughly for any errors or missing information.
08
Sign and date the form at the designated area.
09
Submit the form to the appropriate agency, either by mail or in person.
Who needs HI DHS 1139D?
01
Individuals applying for assistance programs in Hawaii may need to fill out the HI DHS 1139D form.
02
Families seeking financial aid or support services are required to submit this form.
03
Residents who need to report changes in their household status might need to complete this form.
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What is HI DHS 1139D?
HI DHS 1139D is a form used by the Department of Human Services (DHS) in Hawaii to report specific information related to health care services.
Who is required to file HI DHS 1139D?
Entities or individuals providing health care services and receiving reimbursements from the DHS are required to file HI DHS 1139D.
How to fill out HI DHS 1139D?
To fill out HI DHS 1139D, you need to provide relevant personal and service-related information, including patient data, service dates, and payment details, following the instructions provided with the form.
What is the purpose of HI DHS 1139D?
The purpose of HI DHS 1139D is to ensure accurate reporting of health care services rendered and to facilitate proper reimbursement for those services from the DHS.
What information must be reported on HI DHS 1139D?
HI DHS 1139D must report information such as provider details, patient demographics, service descriptions, dates of service, and payment amounts.
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