hospital affiliations form - 6/20181115-26204 06/2018 hospital affiliations provider name: hmsa...

1115-26204 06/2018

Hospital Affiliations

Provider name:

HMSA provider number: National provider identifier (NPI):

To help ensure the accuracy of HMSA’s provider directory information, which helps our members when choosing a PCP or specialist, please take a few moments to complete the information below.

Check off any hospital or medical center you are affiliated with below:

Adventist Health Castle fka Castle Medical Center

Hale Hoola Hamakua fka Honokaa Hospital

Hawaii Medical Center East Kohala Hospital

Kahi Mohala Behavioral Health Kahuku Medical Center Kaiser Permanente

Moanalua Medical Center Lanai Community Hospital

Ka’u Hospital Kauai Veterans Memorial Hospital

Kohala Family Health Center Molokai General Hospital

Kona Community Hospital Kuakini Medical Center Kula Hospital Samuel Mahelona Memorial Hospital

Leahi Hospital Maluhia Maui Memorial Medical Center

The Queen’s Medical Center

North Hawaii Community Hospital Pali Momi Medical Center Rehabilitation Hospital of

the Pacific

Other (please specify): _______________________ _______________________ _______________________ _______________________

Shriners Hospital for Children - Honolulu

Spark M. Matsunaga Veterans Affairs Medical Center

Straub Clinic & Hospital

The Queen’s Medical Center – West Oahu fka Hawaii Medical Center West

Tripler Army Medical Center Hilo Medical Center

Wahiawa General Hospital Wilcox Memorial Hospital Kapiolani Medical Center for Women & Children

If I have signed this Hospital Affiliation Form electronically, it means that I acknowledge and agree to the terms of this Hospital Affiliation Form and so indicate by typing my name below as my electronic signature, executed and adopted by me with the intent to sign this document. In other words, typing my name as an electronic signature indicates that I acknowledge and agree to the terms of this form just as a handwritten signature would on a paper form. Signature Date

Printed or stamped name Social Security number (last four digits only)

Please mail or fax this completed form to:

HMSA Provider Data Administration – KLCR-PDA P.O. Box 860 Honolulu, HI 96808-0860

Phone: 952-7847 on Oahu 1 (800) 603-4672, ext. 7847, toll-free on the Neighbor Islands Fax: 948-8210 on Oahu

Email: Provider_data@hmsa.com