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Click ‘Get Form’ to open the 1147 form in the editor.
Begin by entering the patient’s name in the designated field. Ensure you print or type clearly for legibility.
Fill in the birthdate using the format Month/Day/Year, which is crucial for accurate identification.
Indicate the present address and select whether it is a home, care facility, or other options provided.
Complete sections regarding Medicare eligibility by checking 'Yes' or 'No' for Parts A and B, and provide any necessary ID numbers.
In the assessment section, detail functional status related to health conditions by selecting appropriate options for mobility, communication, and other relevant categories.
Review all entries for accuracy before submitting. Use our platform's features to save your progress as needed.
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DHS 1147 Form - Functional Status related to Health Conditions: Sections III XII are scored. These sections primarily provide information about the individuals functional status as related to his/her health conditions.
What is the difference between MedQuest and Medicaid?
Medicaid, or Med-QUEST in HI, is a health insurance program for low-income individuals of all ages. While this program provides coverage for various groups of Hawaii residents, our focus is on long-term care Medicaid eligibility for elders, aged 65 and over.
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