"Pay to" Tax Indentification Number (TIN): URL Effective Date:

"Pay to" URL/Web Address: Test the URL

Please enter a valid, secure web address. Please enter the complete URL, including https://, etc.
Only (HTTPS) websites will be accepted due to secure communication requirements. Websites using only (HTTP) cannot be submitted.
Some websites may refuse to connect when tested using the Test button on this page. However, you may submit the form if you are sure the URL is correct.

Note: If the provider above already has a URL listed in UHA's online provider search directory, please be aware that the newly entered URL will replace it. The directory lists only one URL per provider.

Authorized Representative Name: E-Mail:

Phone Number:

For questions, contact UHA Customer Services at 522-2268; or toll-free 1-800-458-4600, extension 302, from the neighbor islands

Submit Form

Test Result: Please confirm this is the correct website before submitting the form.

URL Tested: