How to Fill Out Hawaii Form DHS 1147: Scoring and Attachments

Hawaii’s DHS 1147, the Level of Care and At Risk Evaluation, is completed by a registered nurse, physician, or primary care provider — not by the applicant — and captures the patient’s diagnoses, current medications, a scored functional assessment, and any skilled nursing procedures required, before being sent to the applicant’s QUEST Integration managed care plan or the Med-QUEST Division for a determination. If you have been asked how to fill out Hawaii Form DHS 1147, the short version is that the assessor works through the form section by section, adds up the functional scores, attaches any required documentation, signs it, and returns it to the plan named in the “Return Form To” field.¹

Who Signs the Form

Only a registered nurse, physician, or primary care provider can perform the assessment and sign DHS 1147. The assessor’s name, title, phone number, fax number, and email address go on the form. If the form is submitted electronically, the assessor checks a box attesting that a signed hard copy is on file in the patient’s records.²

Applicants and family members still have work to do. You can ask your doctor or care coordinator to initiate the evaluation, and you should be ready to describe daily challenges in detail so the assessor documents functional limitations accurately. The Med-QUEST FAQ notes that you “must complete an application and work with your physician to have your required level of care evaluated” before receiving long-term services and supports.³

Where to Get the Current Form

Use the June 2023 revision. It is available as a downloadable PDF from the Med-QUEST Division’s provider forms page.¹ Providers can also obtain blank copies through the patient’s managed care plan. Hawaii’s five QUEST Integration plans are AlohaCare, HMSA, Kaiser Permanente, ʻOhana Health Plan, and UnitedHealthcare Community Plan.⁴ If you cannot locate it, the Med-QUEST Customer Services Call Center answers at (808) 524-3370 on Oahu or 1-800-316-8005 from the neighbor islands.⁵

Patient Information, Diagnoses, and Medications

The top of the form asks for the patient’s full name, date of birth, Social Security number, and Medicaid ID number. The Medicaid number matters: Med-QUEST will not process the form unless the patient either has a Medicaid number or a Medicaid application date on file.² The form also collects the attending physician or primary care provider’s name, phone, and fax.

The assessor lists primary and secondary diagnoses in the designated fields.¹ Those diagnoses need to match the clinical documentation in the patient’s records. A mismatch between the form and the underlying records is one of the most common reasons evaluations get returned for additional information.

Current medications go in the medication fields. If the patient takes more medications than there are lines for, the assessor attaches a separate orders or treatment sheet.²

Initial Request or Review

Section 11, referral information, is completed in full only for an initial LOC request. For an annual review or another review type, skip Section 11 and go straight to the assessment information in Section 12.² Section 13 is where the assessor checks whether a Level of Care or an At Risk determination is being requested and enters the begin and end dates for the service period.

The Section to Leave Blank

Section 14, Medical Necessity Determination, is not for the assessor. It is filled out exclusively by the DHS reviewer or their designee after the form is submitted. Leave it blank.²

Scoring the Functional Assessment

The functional assessment is the heart of the form. The assessor picks the description that best matches the patient’s current functional status in each category and records the point value. Higher totals reflect greater impairment and a stronger case for nursing-facility-level care.¹

Vision, hearing, and speech: 0 for normal or minimal impairment, 1 for impairment, 2 for complete absence of any of these senses.
Communication: 0 (adequately communicates needs) to 2 (unable to communicate needs).
Memory: 0 (normal) to 2 (problems with both long-term and short-term memory).
Mental status and behavior: 0 (oriented and alert) to 4 (wanders or is in danger of self-harm or self-neglect).
Feeding: 0 (independent) to 2 (spoon-fed, syringe-fed, or tube-fed without participation).
Transferring: 0 (independent) to 4 (does not assist in transfer, requires maximum assistance, or is bedfast).
Mobility and ambulation: 0 (independently mobile) to 5 (unable to walk or immobile).
Bowel continence: 0 (continent) to 3 (incontinent more than once daily or dependent for all bowel care).
Bladder continence: same 0-to-3 scale.
Bathing: 0 (independent) to 3 (cannot bathe without total assistance).
Dressing and personal grooming: scored on a similar scale reflecting the level of hands-on help needed.

Add the points from every category for the total score. Comatose patients are automatically assigned 30 points.² If the lines provided are not enough to describe the patient’s limitations, attach a separate sheet.

Extra Section for At Risk Requests

For At Risk requests only, the assessor also completes four instrumental activities of daily living categories:¹

Housecleaning: independent (0), needs assistance (2), or unable to safely clean the home (3).
Shopping: independent (0), needs assistance (2), or unable to safely go shopping (3).
Laundry: independent (0), needs assistance (1), or unable to safely do laundry (2).
Meal preparation: independent (0), needs assistance (1), or unable to safely prepare a meal (2).

A person who scores low on the core functional assessment but high on these categories may qualify for community-based services like personal care, adult day care, or chore assistance rather than nursing facility placement.³

Skilled Procedures

A separate section lists specific skilled nursing procedures the patient requires, such as wound care, injections, catheter management, or ventilator care. For each procedure, the assessor indicates whether the care is needed daily (and how many times per day), less than once per day, or not applicable.² This section matters for patients whose functional scores alone would not capture the complexity of their care. Someone who can technically dress and feed themselves may still require daily IV medication administration.

Required Attachments

Some situations trigger additional documents that must travel with the form. If hospice services have been elected and will be provided in a nursing facility, attach the hospice election form and physician verification form. If restorative therapy is being requested, attach the evaluation and treatment plan, and note whether the patient can participate in therapy for at least 45 minutes per session, five days a week.² Extra medication or functional-limitation sheets go with the form as well when the printed lines run short.

Where to Send It

The form has a “Return Form To” field for the name of the service coordinator or contact person, along with the managed care plan name if applicable.¹ Completed forms go to the patient’s QUEST Integration plan (AlohaCare, HMSA, Kaiser Permanente, ʻOhana Health Plan, or UnitedHealthcare Community Plan) or directly to the Med-QUEST Division for fee-for-service recipients.⁴

Providers typically submit by fax or a secure electronic portal. Electronic submissions are accepted as long as the assessor checks the attestation box confirming a signed hard copy is in the patient’s file.² Confirming receipt with the plan is worth the phone call. Forms occasionally get lost in transmission, and a missing form means the review clock never starts.

What Happens Next

Once the form is in, a DHS reviewer (or designee) evaluates the medical and functional data and completes the Medical Necessity Determination section. The reviewer may approve nursing-facility-level of care, approve an At Risk determination for community-based services, or deny the request. The applicant then receives a formal Notice of Action stating the decision, the approved level of care, and the reasoning. Keep that notice: it is the official confirmation of clinical eligibility and unlocks long-term services and supports such as adult day care, personal care, chore assistance, skilled nursing, and residential options including Community Care Foster Family Homes and Expanded Adult Residential Care Homes.³

1
Med-QUEST Division. DHS 1147 Hawaii Level of Care and At Risk Evaluation
2
HSAG. Instructions DHS Form 1147 – Level of Care and At Risk Evaluation
3
Med-QUEST. FAQ – Hawaii Medicaid
4
Med-QUEST. Health Plans – Hawaii Medicaid
5
Med-QUEST. Contact Us – Hawaii Medicaid