Online Provider Services Agreement (New Account): Please fill out the form and click Submit Form

Complete the form below. Or, click here to download and submit a paper form.

After you submit this form, UHA must verify your identity in order to execute an Online Provider Services Agreement for your Provider organization.

For questions please call Customer Services at 522-2268, or 800-458-4600, extension 302, from the neighbor islands.



Street
City
State
Zip Code

Enter one or more 9-digit Tax IDs. Please separate each Tax ID with a comma or a space.

Complete the following information and click ENTER for each user you are authorizing to access the UHA Online Provider Services web portal.

User Last Name User First Name User Email Address Add/Term  





The parties agree that this form and all notices and disclosures made or given in connection with this form may be created, executed, delivered and retained electronically. As such, the parties agree that this form and any related documents may be signed electronically, and that the electronic signatures appearing on ths form or any related documents shall have the same legal effect for all purposes, including validity, enforceability and admissibility, as a handwritten signature.
By signing and submitting this form, Provider confirms the accuracy and completeness of the information provided on this form and any attachments, and agrees to be bound by the terms of the UHA Participating Provider Agreement and UHA’s Provider Handbook, which terms shall become effective upon UHA sending a letter giving Provider notice of approval of addition. Provider also confirms his/her intent to be bound by the dispute resolution process described in UHA’s Participating Provider Agreement, described above, which includes binding arbitration of all disputes.