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Frequently Asked Questions

  1. What is the purpose of the Hawaii DHS 1128 form?

    The Hawaii DHS 1128 form is a Disability Report used by the Med-Quest Division of the Department of Human Services. Its main purpose is to gather detailed information about an individual's physical and mental disabilities. This information is crucial for assessing eligibility for various medical assistance programs.

  2. Who needs to complete the DHS 1128 form?

    The form must be completed by a licensed treating physician or evaluator who is familiar with the patient’s medical history and current condition. This ensures that the information provided is accurate and comprehensive.

  3. What kind of information is required on the form?

    The form requires detailed descriptions of significant physical and mental illnesses, accidents, and surgeries related to the patient’s disability. Additionally, it asks for current diagnoses, treatment plans, and an explanation of the patient's functional limitations in performing work.

  4. How should the information be presented on the form?

    All information must be answered completely and legibly. It is essential to provide specific dates for conditions listed and to attach copies of all related medical reports to support the claims made in the form.

  5. What should be included in the treatment plan section?

    The treatment plan should outline the intended approach for managing the patient’s condition, including the duration of treatment. This helps to clarify the ongoing care the patient will receive and its expected impact on their disability.

  6. How does the form address the expected duration of the disability?

    The form includes a section for the physician to indicate whether the disability is expected to be permanent or temporary. This helps the Department of Human Services determine the appropriate level of assistance and the need for future evaluations.

  7. What happens if the patient or their representative does not sign the form?

    If the applicant, recipient, or their guardian does not sign the form, it is necessary to indicate the reason for the absence of a signature. This information is important for processing the application appropriately.

  8. Where should the completed form be submitted?

    The completed DHS 1128 form should be submitted to the appropriate office of the Med-Quest Division. Ensure that all sections are filled out accurately to avoid delays in processing.

  9. Is there a deadline for submitting the form?

    While specific deadlines can vary, it is advisable to submit the form as soon as possible after the physician has completed it. Timely submission helps ensure that the patient's eligibility for assistance is evaluated without unnecessary delays.

  10. Can the form be filled out electronically?

    The DHS 1128 form is typically a paper form that must be filled out by hand. However, it is best to check with the Med-Quest Division for any updates or changes regarding electronic submission options.

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Steps to Writing Hawaii Dhs 1128

Completing the Hawaii DHS 1128 form requires careful attention to detail. This form is essential for documenting a patient's disability and must be filled out accurately to avoid delays in processing. Follow the steps below to ensure that all necessary information is provided clearly and completely.

  1. Start by entering the patient's Name in the designated space. Provide the Date of Birth using the format Mo/Day/Year, and indicate the Sex of the patient.
  2. In the section labeled Licensed Treating Physician/Evaluator, ensure that all questions are answered completely and legibly. This section is crucial for identifying the medical professional responsible for the patient's care.
  3. Describe all significant physical and mental illnesses, accidents, deformities, injuries, and surgeries related to the patient’s disability. Be sure to specify the applicable dates and attach any related reports.
  4. List the Current Diagnoses, starting with the primary diagnosis. Provide up to six diagnoses, ensuring clarity and accuracy.
  5. Outline the Treatment Plan and the expected duration of treatment. This section should detail the approach to managing the patient’s condition.
  6. Explain the patient's Functional Limitations in performing medium and/or light (sedentary) work. Base this explanation on medical evidence rather than subjective judgment, and attach all relevant medical documentation.
  7. In the Licensed Physician’s Statement of Disability section, indicate whether the disability is expected to be permanent (at least 12 months) or temporary, providing the relevant dates as necessary.
  8. Print and sign the name of the Licensed Treating Physician/Evaluator, along with their address, city, zip code, phone number, date, health plan name, and medical provider number or NPI.
  9. In the Patient Acknowledgement section, print and sign the name of the applicant or recipient, along with their contact number and the date of signing. If a guardian or representative is signing, ensure that this is clearly indicated.
  10. If the applicant, recipient, or their representative does not sign, provide a brief explanation in the designated area.

Misconceptions

Understanding the Hawaii DHS 1128 form is crucial for those navigating disability claims. However, several misconceptions can lead to confusion. Here are four common misunderstandings:

  • Misconception 1: The form is only for physical disabilities.

    • This form addresses both physical and mental disabilities. It requires detailed information about any significant conditions affecting the patient, ensuring a comprehensive assessment of their overall health.

  • Misconception 2: Only doctors can fill out the form.

    • While a licensed treating physician or evaluator must sign the form, they can collaborate with other healthcare providers. Input from various professionals can provide a more complete picture of the patient’s condition.

  • Misconception 3: Submitting the form guarantees approval of benefits.

    • Completing the DHS 1128 form does not automatically lead to benefits. The information provided is one part of a larger review process that considers multiple factors before a decision is made.

  • Misconception 4: The form does not require detailed medical evidence.

    • In fact, attaching relevant medical evidence is essential. The form specifically requests documentation to support the claims made about the patient’s disabilities and limitations.