HI DHS 1123 2006 free printable template
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STATE OF HAWAII Department of Human Services Med-QUEST Division P. O. Box 700190 Cupola, HI 96709-0190 AUTHORIZATION TO DISCLOSE CONFIDENTIAL INFORMATION BY THE Med-QUEST DIVISION (MID) (1) (2) PRINT
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How to fill out HI DHS 1123
01
Obtain the HI DHS 1123 form from the official website or local DHS office.
02
Fill in your personal information at the top of the form, including your name, address, and contact details.
03
Provide relevant information about your household, including the number of members and their details.
04
Indicate the purpose of the application clearly in the designated section.
05
Attach any required documents as specified in the instructions.
06
Review the form thoroughly to ensure all information is accurate and complete.
07
Sign and date the form at the bottom.
08
Submit the completed form through the specified method, whether by mail or in person.
Who needs HI DHS 1123?
01
Individuals or families who are applying for social services or benefits in Hawaii may need to fill out the HI DHS 1123 form.
02
This form is typically required for those seeking assistance with food programs, housing, or related services.
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What is HI DHS 1123?
HI DHS 1123 is a form used to report specific information required by the Department of Health Services (DHS) in Hawaii for healthcare providers and organizations.
Who is required to file HI DHS 1123?
Healthcare providers, facilities, and organizations that provide services subject to DHS regulations are required to file HI DHS 1123.
How to fill out HI DHS 1123?
To fill out HI DHS 1123, individuals must provide accurate information as required on the form, including details about their organization, services provided, and any relevant financial data.
What is the purpose of HI DHS 1123?
The purpose of HI DHS 1123 is to ensure compliance with state regulations and to collect necessary data for the oversight and regulation of healthcare services in Hawaii.
What information must be reported on HI DHS 1123?
HI DHS 1123 requires reporting information such as provider details, service types, patient demographics, and financial information related to the services provided.
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