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Dhs1128 instructions disability form edit 2025

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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 reason to believe 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 medical documentation, with patient acknowledgment required.

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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 and clear.
The licensed treating physician/evaluator must complete the form. They should type or print legibly, ensuring that 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 along with the physician’s 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 patient acknowledges the report by signing it. If they do not sign, provide a reason for this omission.
Complete the 'Official Use Only' section if applicable, which is reserved for DHS eligibility workers.
Return all completed forms to the specified address or fax them as indicated in the instructions.

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