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.
Electronic Funds Transfer (EFT) Registration Form: Complete the attached Authorization for Automatic Deposits (Credits) form to receive direct deposit payments from AlohaCare for services billed to AlohaCare 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.
Practitioner Enhancement Attestation Form: Fill out this form to enroll into AlohaCare's 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.

Medical Services Prior Authorization

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 Request: If you are requesting multiple trips, fill this out and attach to the RAN form.

Behavioral Health Prior Authorization

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.
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.