If you need to ADD additional insurance, please make a copy of this sheet, complete and submit together.
DHS 1179A (03/15) Page 1 of 2
STATE OF HAWAII MED-QUEST DIVISION
Department of Human Services
CHANGE OF CIRCUMSTANCE REPORT FORM
You must report any changes to your household (if anyone moves in or out of your household, if anyone gets married,
becomes pregnant, or gives birth to a child), a change in address, income or employment status within 15 days of the
event. If this report does not provide enough room to document a change, attach a sheet of paper with the additional
information. You may also report changes online at www.mybenefits.hawaii.gov, by telephone or in person. Failure to
report changes may result in benefits being denied, terminated or stopped. Auth.: H.A.R. §17-1712.1-4
Primary Individual Name: (Last, First, MI)
Date of Birth: (mm/dd/yyyy)
Current Address (Street, City, State, Zip code):
Phone:
Check one if you are completing on behalf of the Medicaid beneficiary
☐ Authorized Representative
☐ Legal Guardian, POA or Conservator
Requests for change of circumstance by an Authorized Representative, Legal Guardian, Power of Attorney or
Conservator on behalf of the Medicaid beneficiary requires proof of authorization. If the Department does not have a
signed authorization on file from the beneficiary, the request for a change of circumstance on the Medicaid beneficiary’s
behalf will not be processed until proof is received by the Department.
INTERPRETER REQUESTED: ☐ YES ☐ NO
SECTION 1 – TERMINATE MEDICAL ASSISTANCE CASE:
Effective Date: (mm/dd/yyyy)
SECTION 2 - NAME CHANGE: (Attach copy of legal document)
Reason for change:
(complete section 5 if applicable)
SECTION 3: ADDRESS &/OR TELEPHONE CHANGE (This change will apply to ALL household members in your
case, if this is incorrect, please specify in Section 8 who this change applies to.)
SECTION 4 - REPORT OR CHANGE OF PREGNANCY:
Pregnant Woman Name (Last, First, MI)
Date of Birth: (mm/dd/yyyy)
Client ID (or SSN optional):
Number of Babies Expected:
End Date of Pregnancy: (mm/dd/yyyy)
SECTION 5 - REPORT OR CHANGE OF THIRD PARTY LIABILITY (TPL) COVERAGE: (Attach copy of insurance
card if available)
Date of Birth: (mm/dd/yyyy)
Client ID (or SSN optional):
Effective Date of TPL: (mm/dd/yyyy)
Termination Date: (mm/dd/yyyy)
Do you receive Medicare coverage?