Only an Authorized Agent for the provider business entity will be permitted to set up a new account for UHA’s Online Provider Portal and add the additional users of the account.

A representative from UHA’s Contracting Services Department will be calling the provider’s office asking to speak with an Authorized Agent for that provider’s business entity. If we are not able to speak with an Authorized Agent, we will not be able to process your Online Provider Portal Registration request.

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

Complete the form below.

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.

Provider Organization Name:
By checking this box I affirm that I have read and accept the terms and conditions of the UHA Online Provider Services Agreement on behalf of the Provider Organization above.
Organization Address:

Street

City

State

Zip Code

Alabama Alaska Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Rhode Island Puerto Rico South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Enter one or more 9-digit Tax IDs. Please separate each Tax ID with a comma or a space.
Provider Organization Tax ID(s):

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
			Add Term	ENTER

Authorized Representative Name: Authorized Representative Title:
Authorized Representative E-Mail: Authorized Representative Phone:

Other Instructions:

By checking this box I affirm that I am authorized on behalf of my organization to submit this form. I have used all reasonable diligence in submitting the information in this form, and I certify that the information submitted is corrrect.
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.

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