|Provider Information and Credentialing Provider must state whether any of the following events have ever occurred to Provider
If provider’s answer to any of the above is "yes," please provide full explanatory details, including but not limited to the jurisdiction,
date(s), and the nature of the claims or charges resulting in the action noted above, and attach relevant documentation of the Event(s).
List name of Provider’s professional liability insurance carrier, include the policy coverage limits per incident and aggregate.
|UHA requires submission of all the documents listed below to approve your request.
|Please put a checkmark next to documents you will upload. You will be prompted to upload documents after you click the Submit Form button.:
Please note: Any forms received without all the required documentation will be returned with a request to submit all missing information,
For any questions, please call Customer Services at 522-2268, or 800-458-4600, extension 302, from the neighbor islands.
Email Addresses: Please provide email addresses to receive the following types of communication. (for UHA internal use only)