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Dhs 1178 form-2026
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- Click ‘Get Form’ to open the DHS 1178 form in the editor.
- Begin by entering the patient’s name, date of birth, social security number, and Medicaid ID number in the designated fields at the top of the form.
- In Part A, assess if the individual meets criteria for Serious Mental Illness (SMI) by selecting 'YES' or 'NO' for each question. Ensure you provide accurate information based on current diagnoses.
- Proceed to Part B and indicate whether there is a diagnosis of Developmental Disability/Intellectual Disability (DD/ID) by marking 'YES' or 'NO' as applicable.
- If any answers in Parts A or B are 'YES', complete Part C. If all answers are 'NO', sign and date at the bottom of the form.
- Finally, ensure that a physician signs and dates the form before submission to confirm accuracy and compliance.
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See more z204 security clearance form versions
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2013 | 4.9 Satisfied (484 Votes) |
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