Hawaii Forms & Links

 

CCFFH and CMA Forms

• Frequently Asked Questions [FAQ] (pdf)
• Healthcare Provider Numbers Info (pdf)
• Adverse Event Form (pdf)
• Alternate Transportation Plan Form (pdf)
• CCFFH Application Process (pdf)
• CCFFH Application (pdf)
• APS Background Check Form DHS 1507 (pdf)
• Disclosure Form (pdf)
• Filled-Open Client Bed Report Instructions (pdf)
• Filled-Open Client Bed Report Form (pdf)
• Change Request Form (pdf)
• Client Account Record Sample Form (pdf)
• CMA Application (pdf)
• Complaint - Grievance Form (pdf)
• DHS - Criminal History Record Check (pdf)
• Exemption Request Form DHS 1673 (pdf)
• Fingerprint Form DHS 1645 (pdf)
• Fire Drill Sample Form (pdf)
• In Home Job Experience Form (pdf)
• Initial SCG Approval Request Form (pdf)
• Monthly Budget (pdf)
• Personal Belongings Inventory List Sample Form (pdf)
• Rules and Regulations HAR 17-1454 (pdf)
• SCG Change Notification Form (pdf)
• TB Screening Sample Form (pdf)
• Two (2) Year Certificate Requirements (pdf)
• Three (3) Bed Certification (pdf)
• Three (3) Client Certified CCFFH Sign-In Sheet (pdf)

CCFFH/CMA Related Links

• Two CCFFH Private Pay Residents (DHS website)
• CCFFH Fact Sheet (DHS website)
• CMA List (DHS website)
• CCFFH News letter Archive

ADCC Forms

• ADCC Application (pdf)
• ADCC Fingerprint (pdf)
• DHS - Criminal History Record Check (pdf)
• ADCC Rules and Regulations HAR 17-1424 (pdf)

ADCC Related Links

• ADCC Rules and Regulations HAR 17-1424 (DHS website)
• ADCC List (DHS website)

NATP Related Links

• NATP Rules and Regulations HAR 17-1437 (pdf)
• NATP Federal Regulations

Misc. Links

• Adult Protective Services [APS] (DHS website)
• APS Laws & Rules Highlights (DHS website)
• APS Laws & Rules Guideline (DHS website)
• Going Home Plus Program
• Nurse Delegation Rules
• Criminal History Check Rules
• TB Regulations Link 1 and Link 2
• DHS Adult and Community Care Services
• City and County of Honolulu Elderly Affairs Division
• Med-Quest
• Adult Foster Homecare Association of Hawaii
• CNA Recertification - American Red Cross (808) 739-8124
• Fingerprinting and Background Checks - Insights To Success (808) 532-8322 or Neighboring Islands (877) 532-8322

To Report Medicaid Fraud, call: (808) 586-1058

Abuse Hotline: M - F 7:45AM - 4:30PM

• Oahu 832-5115
• Kauai 241-3432
• Maui 243-5151
• Molokai 553-1763
• West Hawaii 327-6280
• East Hawaii 933-8820

Domestic Violence Hotline: 911 or (808) 832-9316

EverCare (888) 980-8728

Ohana Care (888) 846-4262

The Long-Term Care Ombudsman (808) 586-7368