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Dhs1128 instructions disability form edit 2026

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The DHS 1128 Disability Report form is used to assess an individual's eligibility for medical assistance based on blindness or disability. It requires completion by a licensed treating physician when there is reasonable belief that the individual meets the legal definition of disability, which includes an inability to engage in substantial gainful activity due to physical or mental impairments lasting at least twelve months. The form must be filled out completely and accompanied by additional required documents, with patient acknowledgment included.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in your 'Name', 'DOB', and 'Sex' legibly. Ensure that all information is accurate to avoid delays.
The licensed treating physician/evaluator must complete the form. They should type or print legibly, ensuring every question is answered as directed.
Include the physician's printed/typed name, signature, address, phone number, date of signature, and the applicant’s health plan details along with their Medicaid provider number or NPI.
Attach any additional medical information that may support the disability evaluation. This can enhance the assessment process.
Ensure that the applicant or their guardian signs the patient acknowledgment section. If not signed, provide a reason for this omission.
Complete the 'Official Use Only' section if applicable and return all forms to the specified address or fax number provided in the instructions.

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Who is eligible for Quest Hawaii?

You may be eligible for QUEST (Medicaid) if: Youre 19 or older with a total household income at or below 138% of the federal poverty level (for example, $24,826 for a single person or $51,032 for a family of 4 in 2025)

How do I get health insurance in Hawaii?

If you dont have health insurance through an employer, you can buy an individual health plan during the annual Open Enrollment period or see if you are eligible for a Special Enrollment Period through HealthCare.gov.

How to apply for quest insurance in Hawaii?

There are 3 ways to apply for QUEST Health Plan: By phone: Call 877-628-5076 or TTY 711. By written application: See below on how to request an application. Online application: If you apply online at mybenefits.hawaii.gov , you will be automatically enrolled into a health plan that may not be Kaiser Permanente.

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