Hawaii dhs 1128 form-2026

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The document is a Disability Report form from the Med-Quest Division of the Hawaii Department of Human Services. It requires licensed treating physicians to provide detailed information about a patient's significant medical history, current diagnoses, treatment plans, and functional limitations related to their disability. The form also includes sections for the physician's statement on the expected duration of the disability and patient acknowledgment.

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Click ‘Get Form’ to open the Hawaii DHS 1128 form in the editor.
Begin by filling in the patient's name, date of birth, and sex in Section I. Ensure all information is accurate and legible.
In Section II, describe all significant physical and mental conditions related to the patient's disability. Be thorough and attach any relevant reports.
List current diagnoses in Section III, starting with the primary diagnosis. Use clear language for each entry.
Outline your treatment plan and its duration in Section IV. Provide detailed information to support your recommendations.
In Section V, explain the patient’s functional limitations regarding work capabilities based on medical evidence.
Complete Section VI by indicating the expected duration of the disability and signing as the licensed physician.
Finally, have the patient acknowledge their understanding by completing Section VII with their signature and contact number.

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Does Medicaid cover home health care in Hawaii?

In addition to nursing home care, Med-Quest offers residents Medicaid funded care outside of nursing homes. These benefits may include adult day care, home health services, personal emergency response systems, adult foster care, assisted living, and more.

Who is eligible for Medicaid in Hawaii?

Apply for Medicaid in Hawaii Eligibility: Children with family income levels up to 308% of FPL. Pregnant women with family income up to 191% of FPL. Adults with family income up to 138% of FPL.

What is the highest income to qualify for Medicaid?

Who is eligible for California Medicaid? Household Size*Maximum Income Level (Per Year)1$19,3922$26,2283$33,0644$39,9004 more rows

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What is the difference between Medicaid and Medicare in Hawaii?

Medicare is a federal program that provides health coverage if you are 65+ or under 65 and have a disability, no matter your income. Medicaid is a state and federal program that provides health coverage if you have a very low income.

What is the income to qualify for Medicaid in Hawaii?

To know for certain if you qualify, fill out an application at mybenefits.hawaii.gov. As a general guideline, in Hawaii to qualify fo Medicaid if there are four people in your family your income cannot be higher than $3,208 per month.

Hawaii dhs 1128 form-2026

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