Forms and Documents

• Accident Information Form
• HIPAA Authorization for Release of Information
• Notice of Privacy Practices
• Preferred Drug List
• Prescription Drug Claim
• Prescription Drug Exception Form
• Pharmacare Prescription Mail Order Flyer
• Procedures That Are Considered Cosmetic
• Request HDS Subscriber ID Card
• Request Member ID Card
• Screening Checklist for Men
• Screening Checklist for Women
• Services That Require Prior Authorization
• Services That Require Prior Authorization, Effective July 1, 2019
• TCOYD Conference Reimbursement Form

Appeals Documents

• Authorized Representative Form
• Disclosure for Conflicts of Interest Evaluation
• External Review HIPAA Authorization Form
• How To Initiate An Appeal
• If You Disagree With Our Final Decision
• Request for External Review by IRO

Out-of-State Services

• First Health Facilities and Non-Par Mainland Providers
• Medical Travel Checklist
• Notice to Members Regarding Out-of-State Services
• CAUTIONARY NOTICE to Members Regarding Out-of-State Lab Services
• Receiving Medical Care Outside of Hawaii

• Advance Financial Notice
• Authorization for Electronic Funds Transfer (EFT) Provider Form
• Claim Reconsideration Request
  (Provider Claims Action Request Form)   
• Concurrent Care Physician Brochure
• Drugs that Require Prior Authorization
• How To Initiate An Appeal
• ICD-10 Facts
• Letter to Providers RE: OOS Services for Members
• Medical Payment Policies
• Medical Travel Checklist for Out of State Care
• Long Term Opioid Therapy Consent and Medication Agreement
• Online Provider Services - new account ^NEW (no paper form required)
• Online Provider Services - new user ^NEW (no paper form required)

• Online Participating Provider Add Form ^NEW (no paper form required)
• Online Participating Provider Change Form ^NEW (no paper form required)
• Online Participating Provider Service Location Form^NEW (no paper form required)
• Preferred Drug List
• Preferred Drug List (condensed)
• Prescription Drug Exception Form
• Prior Authorization Tool for Medical Services
• Prior Authorization Tool for Prescription Drugs
• Procedures That Are Considered Cosmetic
• Provider Handbook
• Services That Require Prior Authorization
• Services That Require Prior Authorization, Effective July 1, 2019
• Timely Claim Filing Waiver Form
• Vaccination Fee Review Request Form
• W-9

EDI

• Electronic Claim Submission (EDI)
• Electronic Trading Partner Agreement