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Hawaii Level of Care Forms

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 (effective 5/14)
DHS/MQD Form 1147 Instructions (effective 5/14)
Functional Status Assessment Instructions and Examples (effective 5/14)
DHS/MQD Form 1147a (effective 2/1/09)
DHS/MQD Form 1147a Instructions (effective 2/1/09)
DHS/MQD Form 1147e (effective 2/1/09)
DHS/MQD Form 1147e Instructions (effective 2/1/09)

At-Risk Criteria and Process

Click the links below to access and print the most current At Risk information from the Med-QUEST Division:

At Risk for Institutional Level of Care Evaluation Process (memo dated 6/5/14)
Criteria for At-Risk Population (effective 5/14)

Training Materials

Click the links below to access and print helpful information about Hawaii level of care criteria:

State of Hawaii Medicaid Nursing Facility Level of Care 101 PowerPoint Presentation
MedQUEST Long Term Care Services Information