HI DHS 1144B 2013-2025 free printable template
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STATE OF HAWAII Department of Human Services Med-QUEST Division ACS Hawaii Sate Medicaid Fee for Service Program Attn: DUE, P.O. Box 967 Henderson, NC 27536-0967 REQUEST FOR MEDICAL AUTHORIZATION
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How to fill out HI DHS 1144B
01
Obtain the HI DHS 1144B form from the appropriate state department website or office.
02
Read the instructions provided with the form carefully to understand the requirements.
03
Fill out the personal information section, including your name, address, and contact details.
04
Provide the information required about your employment, including your job title and employer's details.
05
Complete the sections related to your income and any relevant financial information.
06
Review all the filled sections for accuracy and completeness.
07
Sign and date the form at the designated area.
08
Submit the completed form to the specified office or online portal as instructed.
Who needs HI DHS 1144B?
01
Individuals applying for assistance or services under the HI DHS program.
02
People who are required to report financial or employment information to the HI DHS.
03
Applicants for specific benefits that necessitate the completion of the HI DHS 1144B form.
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What is HI DHS 1144B?
HI DHS 1144B is a form used by the Hawaii Department of Human Services for reporting certain financial information and activities related to Medicaid and related programs.
Who is required to file HI DHS 1144B?
Entities that provide services reimbursed by Medicaid, including healthcare providers and agencies involved in Medicaid funding, are typically required to file HI DHS 1144B.
How to fill out HI DHS 1144B?
To fill out HI DHS 1144B, gather the required financial documents and details about services provided, then carefully complete the form following the instructions provided by the Hawaii Department of Human Services.
What is the purpose of HI DHS 1144B?
The purpose of HI DHS 1144B is to ensure compliance with state regulations regarding Medicaid funding and to provide a transparent account of expenditures and services rendered.
What information must be reported on HI DHS 1144B?
Information that must be reported on HI DHS 1144B includes details about service providers, the types of services rendered, financial information related to those services, and any other required disclosures related to Medicaid funding.
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