Home
Forms Library
INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he

INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he 2025

INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he Preview on Page 1

See details

4.9 out of 5

370 votes

The document outlines the purpose and instructions for completing Form DHS 1139D, which is required by health care facilities providing acute inpatient hospital services. It must be submitted alongside the DHS 1139 Medicaid Application/Change Request Form.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open it in the editor.
In the first field, enter the 'Print Name of Provider'. This should be the name of the health care facility providing acute inpatient hospital services.
Next, locate the 'Signature' field. Here, you will need to sign your name to validate the form.
Finally, find the 'Date Signed' field and input the date on which you are signing this form. Ensure that this date is accurate as it may be important for processing.

Start using our platform today to fill out your forms online for free!

See more INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he versions

We've got more versions of the INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he form. Select the right INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2008	4.9 Satisfied (370 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can I type my eSignature on my INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he?

Sure, a typed name is accepted as a legitimate electronic signature when you add it to your paperwork utilizing a compliant solution like DocHub. Simply add your INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he to our editor, click Sign in the top tool pane → Create your signature → Type your name in the proper tab, and choose how it will appear on your document.

How do you create an e-signature for the INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he on iOS?

Apart from an extensive toolset for editing PDFs on mobile phones, DocHub allows you to sign your INSTRUCTIONS DHS 1139D (04 08) ACUTE HOSPITAL ATTACHMENT PURPOSE: Form DHS 1139D shall be used by he along the way. Open our editor in your browser, make changes using DocHub’s toolset, and finish your editing by eSigning the finished form.