The Hawaii DHS 1128 form is a critical document used by the Med-Quest Division of the Department of Human Services to assess an individual's disability. This form requires detailed information from licensed treating physicians or evaluators regarding a patient's medical history, current diagnoses, and treatment plans. Completing this form accurately is essential for ensuring that individuals receive the support and resources they need.
The Hawaii DHS 1128 form plays a crucial role in the assessment of individuals applying for disability benefits through the Med-Quest Division of the Department of Human Services. This form is designed to collect comprehensive information regarding a patient's physical and mental health conditions that contribute to their disability. It requires licensed treating physicians or evaluators to provide detailed descriptions of significant illnesses, accidents, and surgeries that relate to the patient's condition. Furthermore, the form asks for current diagnoses, treatment plans, and an evaluation of the patient’s functional limitations, particularly concerning their ability to perform medium and light work. To ensure accuracy and thoroughness, medical evidence must be attached to support the claims made. Additionally, the form includes a section for the physician to indicate whether the disability is expected to be permanent or temporary, along with necessary patient acknowledgments. Completing the DHS 1128 form accurately is essential, as it directly impacts the determination of eligibility for disability benefits in Hawaii.
Filling out the Hawaii DHS 1128 form can be a straightforward process, but there are common mistakes that applicants often make. One significant error is failing to provide complete and legible answers. Each section of the form requires specific information about the patient's medical history and current conditions. If answers are incomplete or difficult to read, the form may be returned, delaying the application process. It is essential to take the time to ensure that all sections are filled out thoroughly and clearly.
Another frequent mistake involves not attaching necessary medical documentation. The form requests copies of all related reports that support the claims made regarding the patient’s disabilities. Omitting these documents can result in the application being deemed insufficient. Applicants should gather all relevant medical records, evaluations, and treatment plans before submitting the form to avoid unnecessary setbacks.
Additionally, some applicants may misinterpret the requirement for listing current diagnoses. The form specifically asks for the primary diagnosis to be listed first, followed by additional diagnoses. Failing to follow this order can lead to confusion and may affect the evaluation of the patient’s condition. Clarity and organization in presenting this information are crucial.
Finally, individuals often overlook the importance of the licensed physician’s statement of disability. This section requires the physician to indicate whether the disability is permanent or temporary and to provide an expected duration. Incomplete or vague statements can lead to further inquiries or rejections. Ensuring that this section is filled out accurately and signed by the appropriate medical professional is vital for a successful submission.
STATE OF HAWAII
Med-Quest Division
Department of Human Services
DISABILITY REPORT
I. Name _________________________________ DOB: _____/_____/_____ Sex: _____
Last
First
MI
Mo
Day
Yr
M/F
LICENSED TREATING PHYSICIAN/EVALUATOR: QUESTIONS MUST BE
ANSWERED COMPLETELY AND LEGIBLY OR FORM MAY BE RETURNED
II.Describe all significant physical and mental illnesses, accidents, deformities, injuries, illnesses and surgeries related to your patient’s disability. Specify date(s) applicable to condition(s) listed and attach copies of all related reports.
_________________________________________________________________________
III.Current diagnoses (List primary diagnosis first)
1._________________________________________________________________
2._________________________________________________________________
3._________________________________________________________________
4._________________________________________________________________
5._________________________________________________________________
6._________________________________________________________________
IV. Indicate your treatment plan and duration of treatment:
V.Explain in detail your patient’s functional limitation(s) in doing medium and/or light (sedentary) work. Base your decision on medical evidence and not on subjective judgment. Attach copies of all medical evidence to this report.
DHS 1128 (Rev. 11/09)
VI. LICENSED PHYSICIAN’S STATEMENT OF DISABILITY
Your patient’s disability is expected to be:
[
PERMANENT
AT LEAST 12 MONTHS, RE-EVALUATION NEEDED: _______________________
(MO/YR)
[] TEMPORARY TO: ______________________
______________________________________________________
__________________________________________________
(Print/Type Name of Licensed Treating Physician/Evaluator)
(Signature of Licensed Treating Physician/Evaluator)
(Address)
(City)
(Zip Code)
(Phone No.)
(Date)
(Name of Health Plan)
(Medical Provider No. or NPI)
VII. PATIENT ACKNOWLEDGEMENT
(Print/Type Name of applicant/recipient)
(Patient Contact Number)
(Signature of applicant/recipient, Guardian or Representative)
If Applicant/Recipient or Guardian or Representative do not sign, indicate reason: ____________
___________________________________________________________________________
FOR OFFICIAL USE ONLY
____________________________________
_______________________________
(Case Name)
(Case No.)
_________________________________________________
(Worker’s Name)
(Section Unit)
(Unit Address)
(Fax No.)
The Hawaii DHS 1128 form is a critical document used for reporting disabilities. Several other documents serve similar purposes in assessing and documenting disabilities. Here are five such documents:
Each of these documents plays a vital role in ensuring that individuals receive the support they need based on their disabilities. Timely and accurate completion is essential for a smooth application process.
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