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 Dhs 1139 Form 2014-2025

Dhs 1139 2014-2025 Form

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What is the DHS 1139 Form

The DHS 1139 form, also known as the Hawaii Medicaid request form, is a crucial document used for applying for Medicaid benefits in Hawaii. This form is specifically designed for individuals seeking assistance with healthcare costs. It gathers essential information about the applicant's financial and personal circumstances to determine eligibility for Medicaid services. Understanding the purpose of this form is vital for anyone looking to access Medicaid benefits in the state.

How to Use the DHS 1139 Form

Using the DHS 1139 form involves several steps to ensure that all necessary information is accurately provided. First, applicants should download the form from the appropriate state resources or complete it online if available. Next, it is essential to fill out the form completely, providing accurate personal information, including income details and household composition. After completing the form, applicants must submit it to the designated state agency for processing. It is advisable to keep a copy of the submitted form for personal records.

Steps to Complete the DHS 1139 Form

Completing the DHS 1139 form requires careful attention to detail. Here are the key steps:

  • Download or access the DHS 1139 form from the official state website.
  • Provide personal information, including your name, address, and Social Security number.
  • Detail your household income and any other financial resources.
  • Include information about any dependents or household members.
  • Review the form for accuracy before submission.
  • Submit the completed form to the appropriate state agency, either online, by mail, or in person.

Legal Use of the DHS 1139 Form

The DHS 1139 form is legally recognized as a valid application for Medicaid benefits within Hawaii. It is essential to use this form in compliance with state regulations to ensure that the application is processed correctly. Providing false information or failing to disclose required details can lead to penalties or denial of benefits. Therefore, applicants should ensure that all information is truthful and complete to maintain compliance with legal standards.

Required Documents

When completing the DHS 1139 form, applicants must provide several supporting documents to verify their eligibility. Commonly required documents include:

  • Proof of income, such as pay stubs or tax returns.
  • Identification documents, such as a driver's license or state ID.
  • Social Security numbers for all household members.
  • Proof of residency in Hawaii, like utility bills or lease agreements.

Having these documents ready can streamline the application process and help avoid delays.

Form Submission Methods

The DHS 1139 form can be submitted through various methods, providing flexibility for applicants. The available submission options typically include:

  • Online submission through the state’s Medicaid portal, if applicable.
  • Mailing the completed form to the designated state agency.
  • In-person submission at local Medicaid offices or community service centers.

Choosing the most convenient method can help ensure that the application is processed in a timely manner.

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