Forms
Find forms that you may need to fill out and return to AlohaCare.
- Provider Credentialing Application: Begin the process of joining AlohaCare’s Provider Network. Please include all supporting documentation if applicable. Fill out this application if you are:
- A provider (non-Hospital based) that is not currently credentialed with AlohaCare
- Facility and Ancillary Provider Profile Form: This application is for all medical and behavioral health treatment facilities, as well as facilities/providers providing long term services and supports (LTSS).
- Hospitals
- SNF
- Ambulatory Surgical Centers
- Home Health Agencies
- Hospice
- Urgent Care Centers (stand-alone)
- Dialysis Centers
- Independent Labs
- DME
- Adult Day Care
- Adult Day Health
- Assisted Living Facilities
- E-Arch
- Personal Care Agencies
- PERS
- Private Duty Nursing
- Respite Care
- AC Online Registration: Sign up to access member eligibility, claim billing and prior authorization information as well as electronic submission of referrals, prior authorization and notifications.
- Provider Enrollment Form: Fill out this application if you are:
- An Anesthesiologist or Radiologist
- A Hospital-based provider and render services solely within the hospital
- A credentialed provider with AlohaCare and are joining a new group/practice.
- Address/Contact Update/Change Form
- Update contact or payment information.
- Change the address of an existing practice location.
- Add another practice location to the same group/practice. If you are adding a location because you are joining a new group/practice, do not use this form. Please complete the Provider Enrollment Application.
- Provider Panel Status Update Form: Complete this form to inform AlohaCare about your panel status and let us know whether you have the ability to accept new members.
- Request for Taxpayer Identification Number and Certification (W-9 Form): Fill out the W-9 Form for our files. We’re required to have your taxpayer identification number and certification on record.
- QI Service Coordination Referral Form: Refer a member to Service Coordination.
- Hospice Information for Medicare Part D Plans: Complete this form to update hospice status or to override an "Hospice A3 Reject."
- PCP Change Form: This form lets members change their Primary Care Provider (PCP).
- Waiver of Liability Form: For Medicare Non-Par Providers Only
- Typically appeals are written requests made by providers disagreeing with the resolution of a grievance. Medicare non-par providers may file an appeal for a denial of payment without submitting a grievance first.
- Medicare non-par providers must complete the Waiver of Liability Form agreeing not to bill an enrollee regardless of the outcome of the appeal.
- Enhancement Program Attestation Form: Complete this form to attest on the behalf of a non-physician under your supervision to enroll in the enhancement program.
- Adverse Event: Report all incidents and events that harm our members who receive long-term services and supports (LTSS).
- Harm can include lack of prescribed services (i.e. caregiver doesn't show up).
- An Adverse Event is an occurrence that may cause harm to a member or LTSS provider. The Adverse Event indicates risk (i.e. abuse, neglect, exploitation) to a member to LTSS provider's health or welfare.
- Injury and Illness Form: Please assist member with completing this form if their injury or illness is related to a work or automotive incident or accident.
- Older Adult Provider Assessment Form: Provider fills out a form about the patient's Advance Care Planning, Functional Status, Assessment, Pain Assessment, and Medication Review for older adults.