Dhs1179a 2026

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  1. Click ‘Get Form’ to open the dhs1179a in the editor.
  2. Begin by entering the 'Case Name' and 'Case No.' at the top of the form. This information is crucial for identifying your case.
  3. Fill in the 'Primary Individual Name' along with their 'Date of Birth' and 'Client ID or SSN'. Ensure accuracy as this data is essential for processing your report.
  4. Complete the 'Current Address' section, including street, city, state, and zip code. Also, provide a contact phone number.
  5. Indicate if you are completing this form on behalf of someone else by checking the appropriate box for 'Authorized Representative' or 'Legal Guardian'.
  6. Proceed through each section (1 to 8) carefully, providing necessary details about changes in circumstances such as address, income, or household members. Attach any required legal documents where indicated.
  7. Finally, review all entered information for accuracy before signing and dating the form at the bottom.

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To enroll into AlohaCare Advantage: You must be a resident of Hawaii. You have full benefit Medicaid coverage and are enrolled in a different QUEST (Medicaid) health plan. You must have Medicare Parts A and B. You must continue to pay for your Medicare Part B premium.
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, $23,888 for a single person or $49,514 for a family of 4 in 2024)
You may be eligible for QUEST if: You are a Hawaii resident; You are a US citizen or qualified immigrant; You provide or apply for a Social Security Number You do not live in a public institution; You are under age 65; You are not blind or permanently disabled; You are not eligible for employer sponsored
QUEST (Medicaid) This Medicaid plan offers medical and behavioral health services at no cost to you.
If you no longer need QUEST (Medicaid) coverage, call Med-QUEST at 1-800-316-8005, (TTY/TDD 711) to let them know.

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You may confirm a members eligibility by checking his or her current QUEST Integration membership card. The card provides you with several pieces of essential information including: The QUEST Integration member number. The name of the PCP and the effective date the member was assigned to the PCP.
Medicaid, or Med-QUEST in HI, is a health insurance program for low-income individuals of all ages. While this program provides coverage for various groups of Hawaii residents, our focus is on long-term care Medicaid eligibility for elders, aged 65 and over.