HI DHS 1139H 2008-2025 free printable template
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STATE OF HAWAII Department Of Human Services Med-QUEST Design Health Coverage Management Brenda P.O. Box 700190 Kappa. Haw 96709-0190 EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT EPS DT SKILLED
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How to fill out epsdt personal provider form
How to fill out HI DHS 1139H
01
Gather necessary personal information such as your name, address, and contact details.
02
Identify the purpose of completing HI DHS 1139H, ensuring you meet the eligibility criteria.
03
Complete the section for income and household information accurately.
04
Provide documentation to support any claims made in the form, such as pay stubs or tax returns.
05
Review the completed form for accuracy and completeness before submission.
06
Submit the form to the designated office as specified in the instructions.
Who needs HI DHS 1139H?
01
Individuals applying for or renewing public assistance programs in Hawaii.
02
Residents who meet specific eligibility requirements for assistance related to food, healthcare, or financial support.
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What is HI DHS 1139H?
HI DHS 1139H is a form used for the reporting of health insurance claims and other pertinent information related to health services provided to individuals.
Who is required to file HI DHS 1139H?
Entities that provide health care services and bill for those services through health insurance plans are required to file HI DHS 1139H.
How to fill out HI DHS 1139H?
To fill out HI DHS 1139H, you need to accurately provide the required information such as patient details, services rendered, and insurance information according to the guidelines specified with the form.
What is the purpose of HI DHS 1139H?
The purpose of HI DHS 1139H is to ensure proper documentation and processing of health insurance claims, facilitating payment from insurance providers for health services rendered.
What information must be reported on HI DHS 1139H?
Information that must be reported on HI DHS 1139H includes the patient’s name, date of birth, service dates, types of services provided, diagnosis codes, and insurance policy details.
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