Dhs 1149-2026

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4.9 out of 5

508 votes

The document is a request form from the State of Hawaii's Department of Human Services, specifically the Med-QUEST Division, for emergency processing of medical assistance applications. It requires completion by a physician for patients with emergent conditions needing immediate treatment that cannot be provided without health insurance. The form includes patient identification details, diagnosis, and urgency of treatment, along with a certification statement from the physician.

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Click ‘Get Form’ to open the DHS 1149 in the editor.
Begin by entering the patient’s legal name in the first field. Ensure you include the first, middle, and last names accurately.
Next, input the patient’s birth date in the designated section. Use the format Month, Day, and Year for clarity.
Fill in the patient’s Social Security Number in the appropriate field to maintain proper identification.
Indicate the date when application form DHS1100 or DHS 1100A was submitted to Med-QUEST. This is crucial for processing timelines.
Provide a detailed diagnosis that necessitates emergency medical services for the patient. Be specific to ensure accurate assessment.
Check all applicable boxes regarding potential risks associated with delaying treatment. This highlights the urgency of care needed.
List any immediate treatments, medications, or medical supplies required that are unavailable without health insurance.
Finally, have the physician sign and date the form, ensuring all information is true and complete before submission.

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Versions	Form popularity	Fillable & printable
2013	4.9 Satisfied (508 Votes)
2008	4.4 Satisfied (173 Votes)

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