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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 (Revised 1/1/21)
DHS/MQD Form 1147 Instructions (Revised 1/1/2021)
DHS/MQD Form 1147a (Revised 1/1/2021)
DHS/MQD Form 1147a Instructions (Revised 1/1/2021)
DHS/MQD Form 1147e (Revised 1/1/2021)
DHS/MQD Form 1147e Instructions (Revised 1/1/2021)
Functional Status Assessment Instructions and Examples (Revised 1/1/2021)
Level of Care Criteria Matrix (Revised 8/6/21)

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