The Hawaii DHS 1128 form is a crucial document used to report disabilities for individuals seeking assistance from the Med-Quest Division of the Department of Human Services. This form collects detailed information about a patient’s physical and mental health conditions, treatment plans, and functional limitations. Completing this form accurately is essential for ensuring that applicants receive the support they need, so take action by filling out the form below.
The Hawaii DHS 1128 form is an essential document for individuals seeking assistance through the Med-Quest Division of the Department of Human Services. This form plays a critical role in the evaluation of disabilities, requiring thorough and accurate information from licensed treating physicians or evaluators. It includes sections that ask for a detailed description of significant physical and mental illnesses, as well as any related accidents or surgeries. The form also necessitates a current list of diagnoses, treatment plans, and an assessment of the patient's functional limitations regarding their ability to perform work. It is imperative that all medical evidence is attached, as subjective judgments are not sufficient. The licensed physician must provide a statement regarding the expected duration of the disability, indicating whether it is permanent or temporary. Additionally, the patient or their representative must acknowledge the information provided by signing the form. Given the importance of this document in determining eligibility for benefits, completing it accurately and promptly is crucial for those in need of assistance.
STATE OF HAWAII
Med-Quest Division
Department of Human Services
DISABILITY REPORT
I. Name _________________________________ DOB: _____/_____/_____ Sex: _____
Last
First
MI
Mo
Day
Yr
M/F
LICENSED TREATING PHYSICIAN/EVALUATOR: QUESTIONS MUST BE
ANSWERED COMPLETELY AND LEGIBLY OR FORM MAY BE RETURNED
II.Describe all significant physical and mental illnesses, accidents, deformities, injuries, illnesses and surgeries related to your patient’s disability. Specify date(s) applicable to condition(s) listed and attach copies of all related reports.
_________________________________________________________________________
III.Current diagnoses (List primary diagnosis first)
1._________________________________________________________________
2._________________________________________________________________
3._________________________________________________________________
4._________________________________________________________________
5._________________________________________________________________
6._________________________________________________________________
IV. Indicate your treatment plan and duration of treatment:
V.Explain in detail your patient’s functional limitation(s) in doing medium and/or light (sedentary) work. Base your decision on medical evidence and not on subjective judgment. Attach copies of all medical evidence to this report.
DHS 1128 (Rev. 11/09)
VI. LICENSED PHYSICIAN’S STATEMENT OF DISABILITY
Your patient’s disability is expected to be:
[
PERMANENT
AT LEAST 12 MONTHS, RE-EVALUATION NEEDED: _______________________
(MO/YR)
[] TEMPORARY TO: ______________________
______________________________________________________
__________________________________________________
(Print/Type Name of Licensed Treating Physician/Evaluator)
(Signature of Licensed Treating Physician/Evaluator)
(Address)
(City)
(Zip Code)
(Phone No.)
(Date)
(Name of Health Plan)
(Medical Provider No. or NPI)
VII. PATIENT ACKNOWLEDGEMENT
(Print/Type Name of applicant/recipient)
(Patient Contact Number)
(Signature of applicant/recipient, Guardian or Representative)
If Applicant/Recipient or Guardian or Representative do not sign, indicate reason: ____________
___________________________________________________________________________
FOR OFFICIAL USE ONLY
____________________________________
_______________________________
(Case Name)
(Case No.)
_________________________________________________
(Worker’s Name)
(Section Unit)
(Unit Address)
(Fax No.)
Hawaii Family Court Case Search - Ensures compliance with Hawaii state laws regarding divorce, providing a legally recognized conclusion to the marriage.
To facilitate a successful transaction, it is essential to utilize a Texas Real Estate Purchase Agreement form, ensuring all terms are clearly defined. For convenience, you can obtain this template through Texas PDF Forms, which provides an efficient way to complete the necessary paperwork.
Polst Form Hawaii - The form is completed in consultation with the patient or their legally authorized representative to ensure it aligns with their preferences.
Hawaii Tax Form N-11 - By filling out Form N-289, sellers of Hawaii property can clarify their tax status to buyers and avoid unnecessary withholding.