Who needs a DHS 1109 form?
This form is a confirmation of pregnancy. It’s required by the Med-QUEST office of Hawaii to assign the free medical care to the pregnant woman. The DHS 1109 must be completed by the health care provider who is attending to the woman.
What is the DHS 1109 form for?
The form is used together with the DHS 1110 to determine if the pregnant woman can get free medical care.
Is the DHS 1109 accompanied by other forms?
This form should be accompanied by Medical Assistance Application (Form DHS 1110).
When is the DHS 1109 due?
The sooner the pregnant woman submits this form, the better. She should ask her doctor or the nurse to fill out the DHS 1109 as soon as she knows the news and before leaving the clinic.
What information should be provided in the DHS 1109 form?
This form asks for the following information:
- Name of the pregnant woman
- Her Social Security Number
- The expected date of the delivery
- Amount of the expected babies
The health provider also must sign, date and print his name in the form.
Where do I send the DHS 1109 form?
The completed and signed form should be forwarded to the Med-QUEST office. You can find the address of the nearest office on the second page of the form.