Forms

Find forms that you may need to fill out and return to AlohaCare.

Credentialing Applications

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

Community Care Foster Family Home Provider Profile
If you are a Hospital-Based Physician, refer to the "General Provider Forms" section below.

General Provider Forms

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.

Medical Service Request Prior Authorization Notification

Request for Prior Authorization/Notification Request : Refer your patients to out of network specialists or request authorization for services/procedures on the prior authorization list.
Ground Transportation Request: If you are requesting multiple trips, fill this out and attach to the RAN form.

Behavioral Health Service Request Prior Authorization Notification

Initial Mental Health Outpatient and/or Chemical Dependency Prior Auth Request Form: For Behavioral Health providers only. Complete this form for BH/CD services that require prior authorization.
Continuing Mental Health Outpatient and/or Chemical Dependency Prior Auth Request Form: For Behavioral Health providers only. Complete this form for BH/CD services that require prior authorization.
Notification of Termination of Behavioral Health Treatment: For Behavioral Health Providers Only: Complete this form when terminating outpatient professional services, or chemical dependency treatment.
Outpatient Psychological Testing Request: For Behavioral Health Providers Only. Complete this form to request outpatient professional psychological or neuropsychological testing.
Request for Applied Behavioral Analysis (ABA) Services: Request ABA services.
Request to Extend End Date of Authorization: Request to extend the end date of a Behavioral Health authorization.

Pharmacy Prior Authorizations

QI Prescription Drug Standard PA Request Form: Request coverage for drugs that are not included on our formulary or require prior authorization.
- Download PDF here.
- Fill out and submit interactive form.
Drug Coverage Request Form
Request for Addition/Deletion of Medication to Formulary: Explain why drugs should be added or deleted from our formulary.
Drug Coverage Request for Anti-Obesity Agents: Request coverage for drugs related to anti-obesity agents.
Oxycontin Drug Coverage Request Form: Request coverage for drugs related to pain management and oxycodone.
Oxycontin Pain Management Agreement Form: Complete this form with your patient when prescribing pain medication.