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HI DHS 1139E 2013-2025 free printable template

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Med-QUEST Division Health Care Services Branch P.O. Box 700190 Cupola, Hawaii 96709-0190 STATE OF HAWAII Department Of Human Services NURSING FACILITY ATTACHMENT Scope of Services (a) The FACILITY
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Begin by downloading the HI DHS 1139E form from the official website.
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Carefully read the instructions provided at the top of the form.
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Fill in the personal information section, including your name, address, and contact details.
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Complete the eligibility section by providing relevant details regarding your background and circumstances.
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Who needs HI DHS 1139E?

01
Individuals applying for assistance or services related to health or human services in Hawaii.
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Families seeking financial support or those in need of assistance programs.
03
Persons who require eligibility determination for various governmental services.
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HI DHS 1139E is a form used by the Department of Human Services in Hawaii, specifically for reporting information related to certain health services.
Individuals or entities that provide specific health services in Hawaii and are subject to compliance with reporting requirements must file HI DHS 1139E.
To fill out HI DHS 1139E, applicants must provide specific information as outlined in the form's instructions, including details about the health services provided, patient information, and the reporting period.
The purpose of HI DHS 1139E is to collect necessary data on health service delivery, usage, and outcomes to improve health programs and policies in Hawaii.
Reported information on HI DHS 1139E includes service provider details, types of services rendered, patient demographics, and any relevant outcome measures related to the health services provided.
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Related Links

Hawaii Medicaid
If you need these services, contact Med-QUEST Division at 1-877-628-5076. If you believe the Department of Human Services/Med-QUEST Division has discriminated ...
FAQ - Hawaii Medicaid
You can call the Med-QUEST Customer Services Call Center at 524-3370 on Ohau or 1-800-316-8005 on neighbor islands. TTY/TDD, call 711.
Hawaii QUEST Expanded
Hawaii's QUEST program is a statewide program, and provides medical, dental, and behavioral health services through competitive managed care delivery ...

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