HCK : Library of Forms

File Name	Size (bytes)	File Description


1DHS1108.pdf	1278040	Health Insurance Application for Children and Pregnant Women Only. Designed for parents and guardians applying for health insurance for their children and/or if a pregnant woman wants health insurance. Includes request for bilingual or sign interpreter, addresses and telephone numbers for Med-QUEST offices statewide, and list of common questions and answers. Lists documents to send with an application. Includes a new form replacing photo identifications for children under sixteen years old and chart listing household size with gross monthly income limits for children's health insurance. Updated June 2009.



2DHS1100.pdf	1458788	Health Insurance Application. If a nonpregnant adult in the household wants health insurance, use this form. Includes request for bilingual or sign interpreter, addresses and telephone numbers for Med-QUEST offices statewide, and lists of common questions and answers. Lists documents to send with an application. Includes a new form replacing photo identifications for children under sixteen years old. Updated June 2009.



3DHS8000K.pdf	126196	Statement of Parent or Guardian for Children Under 16 Years Old. This form is not a health insurance application. It should be attached to the application if a child under 16 years old wants health insurance and does not have an official photo identification. If the children are not living with a parent, the guardian may complete it.



DHS1100a.pdf	135466	Eligibility Determination Form. Used by eligibility worker or outstationed eligibility worker to record and document verification required to establish need and categorical eligibility for all health insurance programs.



DHS1109.pdf	98832	Ten-Day Pending Notice. Informs customer that her/his application or renewal is pending and the specific reason. Updated October 2009.



DHS1123.pdf	133419	Authorization to Disclose Confidential Information by Med-QUEST Division. Allows Med-QUEST to release information about the customer to a designated representative.



DHS1124.pdf	95995	Consent to Release Information to the Med-QUEST Division. Initiates applicant's written consent for Med-QUEST to get appropriate information from a specific third party. Updated November 2005.



DHS1125.pdf	71583	Assignment of Payment, Repayment Agreement, and Authorization and Waiver for Release of Information. Completed for each applicant injured in an incident, accident, or accident-related case where a third party may be liable for medical expenses paid by the Hawaii State Department of Human Services on behalf of the customer. Allows state and federal governments to recover paid medical expenses and to obtain necessary patient records. Must not contain any amendments, additions, attachments, or changes.



DHS1125A.pdf	269852	Supplement to Assignment of Payment Supplement to DHS1125. Specific information necessary to identify cases where medical payment recovery can be initiated on behalf of customers. Each household member injured in an accident must complete a separate form. Updated October 2004.



DHS1127.pdf	210721	Medical History and Disability Statement. Submitted to the Aid to Disabled Review Committee (ADRC) to help determine disability by evaluating a customer's medical/psychosocial profile, education level, and previous work experience.



DHS1128.pdf	111780	Disability Report. Initiated by health plan or eligibility worker if the customer may meet the lawful definition of a disabled person. Completed by a licensed physician or authorized evaluator.



DHS1134.pdf	21117	Medical Assistance Standards. Income levels for household sizes. Updated September 2009.



DHS1138.pdf	91594	Medicaid Eligibility for the H&CB Waiver Program. Completed for home and community-based waiver services.



DHS1149.pdf	26254	Request for Application Emergency Processing. Completed by physician or dentist certifying an emergent condition that will not be treated without health insurance. Revised February 2008.



DHS1160.pdf	113414	Request for Individualized Transportation Services. Completed by physician and customer and given to eligibility worker.



DHS1163.pdf	156367	Application and Disposition for Funeral Payments. Completed by a deceased person's family member or agency representative requesting assistance to pay for a funeral company's services.



DHS1167.pdf	42963	Statement of Intent for Applicants/Recipients in Long Term Care Facilities. Customer states that she/he will return to her/his home if able, therefore the home will not be counted as an asset while she/he is in long-term care.



DHS1169.pdf	192195	Evaluation for the Placement of Liens. Used to determine if the state should place a lien on the customer's home property for nursing home health insurance. Updated July 2007.



DHS1180.pdf	111171	GA/ADRC Referral and Determination. Referral completed by eligibility worker or physician and sent to the Disabled Review Committee. Updated November 2007.



DHS1246.pdf	333785	Income Maintenance Case Recording Sheet. Eligibility worker or outstationed eligibility worker records chronological facts and events.



DHS1248A.pdf	60773	Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Obtaining Third Party Payments. Note: This is a duplicate form therefore the applicant keeps a signed copy. Specific information on how the right to good cause can be pursued by the applicant.



DHS1266.pdf	24748	Employment Record and Payroll Certification Form. Verifies the customer's employment record when she/he is unable to provide the information and agrees to have an eligibility worker or outstationed eligiblity worker contact the employer. Updated February 2003.



DHS1266a.pdf	58972	New Employment Form. Verifies the customer's new employment when she/he cannot provide the information and agrees to have an eligibility worker or outstationed eligibility worker contact the employer.



DHS1267.pdf	57406	Financial Status. Verifies the customer's financial status (e.g., bank, savings and loan, credit union, etc.) when she/he cannot provide the information and agrees to have an eligibility worker or outstationed eligibility worker contact the institution.



DHS1270.pdf	462995	Physical Examination Report. Initiated by an eligibility worker when there is reason to believe a customer's physical condition prevents her/him from engaging in any substantial gainful activity.



DHS1271.pdf	736350	Psychiatric Evaluation Report. Completed by a Med-QUEST authorized psychiatrist or psychologist for a customer claiming a psychological disability.



DHS1273b.pdf	381869	Report of Earnings. Documents gross wages and tips, medical premium deductions, hours worked, year-to-date earnings, and other employment information for each employed person.



DHS1273C.pdf	182477	Report of Self-Employment Earnings. Completed by self-employed customer to provide information on self-employment earnings.



DHS1301.pdf	120198	Absent Parent Referral (ABPR) to Child Support Enforcement Agency. Absent parent information is recorded and applicant signs penalty of perjury statement.



DHS1460.pdf	102158	Application Interview Appointment. Explains date, time, place, and interviewer and what to bring to the interview.



DHS1461.pdf	517849	Request for Administrative Hearing. For customer who does not agree with the action taken by the Hawaii State Department of Human Services. Used for health insurance, financial assistance, social services, food stamps, and other benefits.



DHS1465.pdf	74399	Consent to Review/Release Information from Case Record. Allows specific third party, customer, or legal guardian to review and/or receive specific information from Department of Human Services' case records.



DHS1475.pdf	105408	Referral for Social Security Number. Feedback form between Med-QUEST and the Social Security Administration. Provides verification from the Social Security Administration to Med-QUEST on the application status for a new or duplicate social security number. Can also be used to inform the eligibility worker of the customer's social security number.



ESHIF.pdf	44623	Employer Health Insurance Information. Verification that health insurance is not available to the customer by her/his employer.



HIBirthCertApp.pdf	555905	Information and application to request a certified birth certificate from the Hawaii State Department of Health.



HIDeathCertApp.pdf	551134	Information and application to request a certified death certificate from the Hawaii State Department of Health.



SEBEXP.pdf	34182	Itemized Record of Self-Employment Business Expenses. Worksheet for customer to record business operating expenses.



SEBINC.pdf	26163	Itemized Record of Self-Employment Business Income. Worksheet for customer to record money received from her/his business.



SSCardApp.pdf	134307	Social Security Administration's Application for a Social Security Card. Instructions and application for a new, duplicate, or corrected card.

Library of Forms

Home

Kids Health Insurance Hotline
211
Free Call From All Islands