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

Complete the form below to request changes to information previously reported to UHA or to terminate a provider. Or, click here to download and submit a paper form.

To add new Providers to your UHA contract you must complete the Participating Provider Add form. For questions please call Customer Services at 522-2268, or 800-458-4600, extension 302, from the neighbor islands.


Information to be changed is shown below.

(required)

CURRENT ADDRESS: CONTACT INFORMATION: CHANGE ADDRESS TO:
(Use this section if you are changing your address.)
1.  Current Address

 City

 State Zip

 Office Telephone:

 Fax Number:

 E-Mail Address:

 New Address

 City

 State Zip

Physical Address
Correspondence Address
Remittance/Pay To Address
Handicap Accessible
(check all that apply)
2.  Current Address

 City

 State Zip

 Office Telephone:

 Fax Number:

 E-Mail Address:

 New Address

 City

 State Zip

Physical Address
Correspondence Address
Remittance/Pay To Address
Handicap Accessible
(check all that apply)
3.  Current Address

 City

 State Zip

 Office Telephone:

 Fax Number:

 E-Mail Address:

 New Address

 City

 State Zip

Physical Address
Correspondence Address
Remittance/Pay To Address
Handicap Accessible
(check all that apply)
4.  Current Address

 City

 State Zip

 Office Telephone:

 Fax Number:

 E-Mail Address:

 New Address

 City

 State Zip

Physical Address
Correspondence Address
Remittance/Pay To Address
Handicap Accessible
(check all that apply)


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Note: If you need to terminate a contract (an individual provider contract or your group contract), please submit your request in writing to UHA's Contracting Services Department.