HI DHS 204 2007-2025 free printable template

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ACS HAWAII STATE MEDICAID FEE FOR SERVICE PROGRAM Attention: Claims P. O BOX 967, HENDERSON, NC 27536 PRESCRIPTION DRUG CLAIM Identification Number 1 Recipient's Name 2 Pharmacy NPI 4 Date of Birth

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How to fill out HI DHS 204

01

Obtain the HI DHS 204 form from the official website or local office.

02

Fill in the personal information section, including your name, address, and contact details.

03

Provide details about the service or program you are applying for.

04

Attach any required documents, such as proof of income or identity.

05

Review the form for accuracy and completeness.

06

Sign and date the form at the designated space.

07

Submit the completed form to the appropriate office or department.

Who needs HI DHS 204?

01

Individuals applying for assistance programs offered by the Hawaii Department of Human Services.

02

Families seeking financial aid or support services.

03

Persons in need of healthcare benefits or resources.

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What is HI DHS 204?

HI DHS 204 is a form used by the Hawaii Department of Human Services to report certain data related to health and human services programs.

Who is required to file HI DHS 204?

Organizations or individuals that provide specific health and human services in Hawaii and are subject to reporting requirements are required to file HI DHS 204.

How to fill out HI DHS 204?

To fill out HI DHS 204, ensure that all required fields are completed accurately, provide necessary documentation, and submit the form to the appropriate agency by the specified deadline.

What is the purpose of HI DHS 204?

The purpose of HI DHS 204 is to collect data to monitor and evaluate the effectiveness of health and human services programs in Hawaii.

What information must be reported on HI DHS 204?

The information that must be reported on HI DHS 204 includes service delivery data, client demographics, outcomes of services provided, and financial information related to funding and expenditures.

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