Participating Provider Add Form: Please fill out the form and click Submit Form

Complete the form below to add new Providers to your UHA contract. Or, click here to download and submit a paper form.

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




(required)
Provider Information and Credentialing   Provider must state whether any of the following events have ever occurred to Provider
Suspension, termination or restriction of any medical license or certificate held by Provider, or of any DEA license or state controlled substances certificate by Provider, in any jurisdiction? Yes   No
Provider’s indictment for or conviction of a fraud or felony arising out of or related to the Provider’s professional medical capacity or the rendering of health care? Yes   No
Provider’s disqualification from participating in any government health care program, including Medicare or QUEST? Yes   No
Provider’s having a physical or mental condition that interferes with his/her ability to safely perform health care services? Yes   No

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.
per incident, 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.:
Copy of current certification if American Board of Specialty
Copy of each rendering provider’s Hawaii State Provider License
Copy of each rendering provider’s Federal DEA number, if applicable
Copy of each rendering provider’s NPI notification

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)

PHYSICAL LOCATION ADDRESS(ES)
for Provider’s Medical Office(s)
CONTACT INFORMATION PAY TO/REMITTANCE MAILING ADDRESS
1.  Primary Location Address

 City

 State Zip

 Office Telephone:

 Fax Number:

Handicap Accessible
Post location on UHA Provider Directory
 Primary Location Address

 City

 State Zip

2.  Additional Location Address

 City

 State Zip

 Office Telephone:

 Fax Number:

Handicap Accessible
Post location on UHA Provider Directory
 Additional Location Address

 City

 State Zip

3.  Additional Location Address

 City

 State Zip

 Office Telephone:

 Fax Number:

Handicap Accessible
Post location on UHA Provider Directory
 Additional Location Address

 City

 State Zip


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