1200a department med form 2026

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The document is a request form (DHS 1200) from the Department of Human Services' Med-QUEST Division for individuals seeking an exemption from criminal history record and background check standards. It outlines the purpose, utilization, and completion instructions for the form, which is required for those working with organizations contracted to provide direct services to Medicaid beneficiaries. Each exemption request requires a separate form, and personal information along with reasons for the exemption must be provided.

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Click ‘Get Form’ to open the 1200a department med form in the editor.
In Section I, enter your personal information. This includes your name, signature, social security number, date of birth, home and mailing addresses, as well as your home and business telephone numbers.
Proceed to Section II, where you will provide reasons for your exemption. Carefully respond to each question listed in this section.
Once all sections are completed, review the form for accuracy. Ensure that all required fields are filled out correctly.
Submit the completed form by returning it to Fieldprint, Inc. at the specified address. Remember to keep a copy for your records.

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