Oct 01, 2020 · Serious Mental Illness SMI 1157 Instructions The DHS 1157, Referral for Serious Mental Illness (SMI) to the Community Care Services (CCS) Program, shall be initiated by the health plan or hospital when there is reason to believe that an applicant/recipient of financial and/or medical assistance may meet the definition of SMI and would meet the criteria to …

Hawaii Level of Care Forms and Resources. Click the links below to access and print the most-current evaluation forms and instructions approved by the Med-QUEST Division: DHS/MQD Form 1147 (Revised 1/1/21) DHS/MQD Form 1147 Instructions (Revised 1/1/2021) DHS/MQD Form 1147a (Revised 1/1/2021)

State of Hawaii Med-QUEST Division, Clinical Standards Office Department of Human Services DHS 1157 (Rev. 09/13) Page 1 of 3 . REFERRAL FOR SERIOUS MENTAL ILLNESS (SMI) COMMUNITY CARE SERVICES (CCS) ... Process or Form: Loose associations [ ] Poverty of content [ ] Flight of ideas [ ] ...

Serious Mental Illness 1157 Application Form - English (PDF) Serious Mental Illness SMI 1157 Instructions - English (PDF) Specialized Residential Treatment SRT Authorization - English (PDF) Steps for Root Cause Analysis - English (PDF) Claims. CMS 1500 Submission Sample - English (PDF) Dental Claims Encounter Guide - English (PDF) (Coming Soon)

Hawaii

Fill out the application as completely as possible. Print the completed application and mail, fax or drop off the completed application to the Med-QUEST Division Eligibility Office nearest your home address. DHS 1100 “Application for Health Coverage and Help Paying Costs ”. DHS 1100 Instructions. Telephone, Fax, or Mail. Phone at 1-877-628 ...

AMHD REFERRAL FORM. Page 5 of 5. DOH AMHD Referral Form (02/07/08) DEPARTMENT OF HEALTH. ADULT MENTAL HEALTH DIVISION. REFERRAL FORM. DOH AMHD Referral Form (01 12 15) AMHD REFERRAL FORM. Page 6 of 6. DOH AMHD Referral Form (1/12/15)

STATE OF HAWAII Department of Human Services Med-QUEST Division STATE OF HAWAII Level of Care (LOC) and At Risk Evaluation HEALTH SERVICES ADVISORY GROUP, INC. 1440 Kapiolani Blvd., Suite 1110 Honolulu, HI 96814 Phone: (808) 440-6000 Fax: (808) 440-6009 DHS 1147 (Rev. 05/14) DO NOT MODIFY FORM Page 2 of 3

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State of Hawaii, Department of Human Services. Personnel Office / Civil Rights Compliance Staff. P. O. Box 339. Honolulu, Hawaii 96809-0339. (808) 586-4955 or 711 for relay services. DHSCivilRightsBox@dhs.hawaii.gov. You may file a discrimination complaint in person or by mail, fax, or email.