Form DHS 1106 Cws/Mqd Communication Form (Foster Care) - Hawaii

Form DHS1106 or the "Cws/mqd Communication Form (foster Care)" is a form issued by the Hawaii Department of Human Services.

The form was last revised in July 1, 2018 and is available for digital filing. Download an up-to-date Form DHS1106 in PDF-format down below or look it up on the Hawaii Department of Human Services Forms website.

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STATE OF HAWAII
Med-QUEST Division
Department of Human Services
CWS/MQD COMMUNICATION FORM (FOSTER CARE)
 New  Change  Verification of Previous CWS Assistance
Please Print or Type
CWS comments: (If “Change” selected, write what was changed here)
SECTION 1
WORKER INFORMATION (To be completed by CWS SW/HSP or MQD)
1.
2.
3.
4.
5.
Receiving Division:
Section/Unit
Receiving MQD/SSD Worker Name
Effective Date
Date faxed/sent
TO:
MQD
SSD
6.
7.
8.
9.
10.
Sending Division:
Unit No.
Sending Worker Name
Phone No.
Fax No.
FROM: 
MQD
SSD
11.
12.
13.
14.
Unit Address
Unit City/State/Zip
Supervisor Name
Supervisor Phone No.
SECTION 2
CHILD INFORMATION
Child’s Last Name
Child’s First Name
15.
16.
17.
18.
19.
Middle Name
Suffix
Gender
20.
21.
22.
23.
24.
DOB
SSN
ICPC or ICAMA
IV-E Status
Placement
 IV-E
 Hawaii
(attach ICAMA 7.01 form)
 Yes
 Non-IV-E
 Out of State
 No
 Pending
25.
26.
24a
CWS Case No.
KOLEA Client ID
. Placement Type
Effective date:
 Adoption
________
 Foster Care
27.
28.
29.
30.
31.
32.
Pregnant?
E.D.D.
No. of Babies
Retro Coverage? (
Permanent Disability?
Disability Determination
up to 10
 Yes
 Blind
 SSI/SSDI Date ____
days prior to MQD received date)
 Yes
 No
 No
 Disabled
 ADRC (Attach form)
Date(s): _____________
 Photo
33.
34.
Lawfully Present non-citizen
Name of Medical Insurance
Information
 U.S. Birth Certificate
Qualified non-citizen
on file:
 Document Type:
ID No.:
35.
36.
Foster Parent(s) Name(s)
Relationship to Child
FAMILY INFORMATION
Biological Mother’s Last Name
37.
38.
39.
40.
41.
42.
First Name
M.I.
KOLEA Client ID
SSN
DOB
Biological Father’s Last Name
43.
44.
45.
46.
47.
48.
First Name
M.I.
KOLEA Client ID
SSN
DOB
SECTION 3
PLAN SELECTION
49.
Requested Plan Name
SECTION 4
CHANGES IN KINSHIP/GUARDIANSHIP/FOSTER CARE/ADOPTION SUBSIDY STATUS
50.
51.
Reason for Change of medical assistance:
Reason for Termination of medical assistance:
 Aging Out
 Returned to legally responsible family/Added to family medical case
 Voluntary FC to Age 21
 Kinship/Guardianship/Subsidized Adoption prior to age16
 Kinship/Guardianship/Subsidized Adoption at age16 or older
 Other Reason:___________________________________
 Other Reason:___________________________________
52.
53.
54.
Parent/Legal Representative or Contact Name
Relationship
KOLEA Client ID
Child’s Residence Address
Child’s Mailing Address (if different)
55.
56.
57.
58.
59.
KOLEA Case No.
Case Name
Date Case Opened
01
__ __ __ __ __ __ __ __ -
SECTION 5
VERIFICATION OF PREVIOUS CWS ASSISTANCE
60.
Previous beneficiary of:
Kinship/Guardianship/Subsidized Adoption –
 Foster Care Aging Out
Age when approved : ____________
Age when terminated: ____________
 KOLEA ID: _______________
Age when terminated: _______ ____
61.
62.
63.
Verified by: (CWS Worker Name)
Title
Phone No.
DHS 1106 (Rev. 07/18)
Page 1 of 1
STATE OF HAWAII
Med-QUEST Division
Department of Human Services
CWS/MQD COMMUNICATION FORM (FOSTER CARE)
 New  Change  Verification of Previous CWS Assistance
Please Print or Type
CWS comments: (If “Change” selected, write what was changed here)
SECTION 1
WORKER INFORMATION (To be completed by CWS SW/HSP or MQD)
1.
2.
3.
4.
5.
Receiving Division:
Section/Unit
Receiving MQD/SSD Worker Name
Effective Date
Date faxed/sent
TO:
MQD
SSD
6.
7.
8.
9.
10.
Sending Division:
Unit No.
Sending Worker Name
Phone No.
Fax No.
FROM: 
MQD
SSD
11.
12.
13.
14.
Unit Address
Unit City/State/Zip
Supervisor Name
Supervisor Phone No.
SECTION 2
CHILD INFORMATION
Child’s Last Name
Child’s First Name
15.
16.
17.
18.
19.
Middle Name
Suffix
Gender
20.
21.
22.
23.
24.
DOB
SSN
ICPC or ICAMA
IV-E Status
Placement
 IV-E
 Hawaii
(attach ICAMA 7.01 form)
 Yes
 Non-IV-E
 Out of State
 No
 Pending
25.
26.
24a
CWS Case No.
KOLEA Client ID
. Placement Type
Effective date:
 Adoption
________
 Foster Care
27.
28.
29.
30.
31.
32.
Pregnant?
E.D.D.
No. of Babies
Retro Coverage? (
Permanent Disability?
Disability Determination
up to 10
 Yes
 Blind
 SSI/SSDI Date ____
days prior to MQD received date)
 Yes
 No
 No
 Disabled
 ADRC (Attach form)
Date(s): _____________
 Photo
33.
34.
Lawfully Present non-citizen
Name of Medical Insurance
Information
 U.S. Birth Certificate
Qualified non-citizen
on file:
 Document Type:
ID No.:
35.
36.
Foster Parent(s) Name(s)
Relationship to Child
FAMILY INFORMATION
Biological Mother’s Last Name
37.
38.
39.
40.
41.
42.
First Name
M.I.
KOLEA Client ID
SSN
DOB
Biological Father’s Last Name
43.
44.
45.
46.
47.
48.
First Name
M.I.
KOLEA Client ID
SSN
DOB
SECTION 3
PLAN SELECTION
49.
Requested Plan Name
SECTION 4
CHANGES IN KINSHIP/GUARDIANSHIP/FOSTER CARE/ADOPTION SUBSIDY STATUS
50.
51.
Reason for Change of medical assistance:
Reason for Termination of medical assistance:
 Aging Out
 Returned to legally responsible family/Added to family medical case
 Voluntary FC to Age 21
 Kinship/Guardianship/Subsidized Adoption prior to age16
 Kinship/Guardianship/Subsidized Adoption at age16 or older
 Other Reason:___________________________________
 Other Reason:___________________________________
52.
53.
54.
Parent/Legal Representative or Contact Name
Relationship
KOLEA Client ID
Child’s Residence Address
Child’s Mailing Address (if different)
55.
56.
57.
58.
59.
KOLEA Case No.
Case Name
Date Case Opened
01
__ __ __ __ __ __ __ __ -
SECTION 5
VERIFICATION OF PREVIOUS CWS ASSISTANCE
60.
Previous beneficiary of:
Kinship/Guardianship/Subsidized Adoption –
 Foster Care Aging Out
Age when approved : ____________
Age when terminated: ____________
 KOLEA ID: _______________
Age when terminated: _______ ____
61.
62.
63.
Verified by: (CWS Worker Name)
Title
Phone No.
DHS 1106 (Rev. 07/18)
Page 1 of 1

Download Form DHS 1106 Cws/Mqd Communication Form (Foster Care) - Hawaii

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