hospital affiliations form - 6/20181115-26204 06/2018 hospital affiliations provider name: hmsa...
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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: [email protected]