Skip Main Navigation Skip Left Navigation

Forms


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

ALOHACARE QUEST

  1. Begin the process of joining AlohaCare’s Provider Network by completing the appropriate provider profile
    Behavior Health Provider Profile Form (Updated 08/2013) 
    Facility & Ancillary Provider Profile Form (Updated 03/2014) 
    Physician Assistant Provider Profile Form (Updated 08/2013) 
    Primary Care Provider Profile Form (Updated 08/2013) 
    Specialist Provider Profile Form (Updated 08/2013)
  2. 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. (Updated 12/2013)
      
  3. 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. 
     
  4. Provider Complaint: File a complaint with AlohaCare about our services or our members. (Updated 10/2009) 
     
  5. Electronic Funds Transfer (EFT): Complete this form to receive direct deposit payments from AlohaCare for services billed provided to AlohaCare members. A copy of a voided check, current PVL and this form may be submitted to AlohaCare's Provider Relations Department via USPS or may be faxed to 973-0811. (Updated 8/2012)
     
  6. Address/Contact Update/Change FormChange addresses or contact information. (Updated 3/2013)
     
  7. Referral/Prior Authorization/Notification Request: Refer your patients to specialists or request authorization for services/procedures on the prior authorization list. (Updated 1/2014)
     
  8. Drug Coverage Request: Request coverage for drugs that are not included on our formulary or require prior authorization. (Updated 10/2010)
     
  9. Request for Addition/Deletion of Medication to Formulary: Explain why drugs should be added or deleted from our formulary.
     
     
  10. Notification of Termination of Behavioral Health Treatment: For Behavioral Health Providers Only: Complete this form when terminating outpatient professional services, or chemical dependency treatment. (Updated 7/2010) 
     
  11. Behavioral Health Outpatient and/or Chemical Dependency Interval Treatment PlanFor Behavioral Health Providers only. Complete this form when more than 15 hours of outpatient professional sessions or continuing chemical dependency services are needed.  Do you need help filling out this form? See instructions of how to fill it out. (Updated 12/2013)
     
  12. Outpatient Psychological Testing Request: For Behavioral Health Providers Only. Complete this form to request outpatient professional psychological or neuropsychological testing. (Updated 7/2010)
     
  13. Drug Coverage Request for Anti-Obesity Agents: Request coverage for drugs related to anti-obesity agents. (Updated 9/2010)
     
  14. Pain Medication Agreement: Complete this form with your patient when prescribing pain medication. (Updated 9/2010)
     
  15. Drug Coverage Request for Oxycodone: Request coverage for drugs related to pain management and oxycodone. (Updated 9/2010)
     

ALOHACARE ADVANTAGE (HMO)

 
  1. Begin the process of joining AlohaCare’s Provider Network by completing the appropriate provider profile.
    Behavior Health Provider Profile Form (Updated 08/2013) 
    Facility & Ancillary Provider Profile Form (Updated 03/2014) 
    Physician Assistant Provider Profile Form (Updated 08/2013) 
    Primary Care Provider Profile Form (Updated 08/2013) 
    Specialist Provider Profile Form (Updated 08/2013)
     
      
  2. 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. (Updated 12/2013)

  3. 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.
     
  4. Provider Complaint: File a complaint with AlohaCare about our services or our members. (Updated 10/2009)
     
  5. Electronic Funds Transfer (EFT): Complete this from to receive direct deposit for payments from AlohaCare for services billed provided to AlohaCare members. A copy of a voided check, current PVL and this form may be submitted to AlohaCare's Provider Relations Department via USPS or may be faxed to 973-0811. (Updated 8/2012)
     
  6. Address/Contact Update/Change Form: Change addresses or contact information. (Updated 3/2013)
     
  7. Referral/Prior Authorization/Notification Request: Refer your patients to specialists or request authorization for services/procedures on the prior authorization list. (Updated 1/2014)
     
  8. Drug Coverage Request: Request drug coverage for drugs that are not on the formulary, require authorization, have limitations or tier change. (Updated 10/2010)
     
  9.  Request for Addition/Deletion of Medication to Formulary: Explain why drugs should be added or deleted from our formulary.
     
  10. Medicare Part D Coverage Determination Request: Request an authorization or an exemption to our formulary.
     
     
  11. Notification of Termination of Behavioral Health Treatment: For Behavioral Health Providers Only: Complete this form when terminating outpatient professional services, or chemical dependency treatment. (Updated 7/2010)
     
  12. Behavioral Health Outpatient and/or Chemical Dependency Interval Treatment PlanFor Behavioral Health Providers only. Complete this form when more than 15 hours of outpatient professional sessions or continuing chemical dependency services are needed.  Do you need help filling out this form? See instructions of how to fill it out. (Updated 12/2013)
     
  13. Outpatient Psychological Testing Request: For Behavioral Health Providers Only. Complete this form to request outpatient professional psychological or neuropsychological testing. (Updated 7/2010)
     


     

ALOHACARE ADVANTAGE PLUS (HMO SNP)


  1. Begin the process of joining AlohaCare’s Provider Network by completing the appropriate provider profile.
    Behavioral Health Provider Profile Form (Updated 08/2013) 
    Facility & Ancillary Provider Profile Form (Updated 03/2014) 
    Physician Assistant Provider Profile Form (Updated 08/2013) 
    Primary Care Provider Profile Form (Updated 08/2013) 
    Specialist Provider Profile Form (Updated 08/2013)
  2. 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. (Updated 12/2013)

  3. 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.
     
  4. Provider Complaint : File a complaint with AlohaCare about our services or our members. (Updated 10/2009) 
     
  5. Electronic Funds Transfer (EFT): Complete this from to recieve direct deposit payments from AlohaCare for services billed provided to AlohaCare members. (Updated 8/2012)
     
  6. Address/Contact Update/Change Form: Change addresses or contact information. (Updated 3/2013)
     
  7. Referral/Prior Authorization/Notification Request : Refer your patients to specialists or request authorization for services/procedures on the prior authorization list. (Updated 1/2014)
     
  8. Drug Coverage Request : Request drug coverage for drugs that are not on the formulary, require authorization, have limitations or tier change. (Updated 10/2010)
     
  9. Request for Addition/Deletion of Medicare to Formulary : Explain why drugs should be added or deleted from our formulary. 
     
  10. Medicare Part D Coverage Determination Request : Request an authorization or an exemption to our formulary.
     
     
  11. Notification of Termination of Behavioral Health Treatment: For Behavioral Health Providers Only: Complete this form when terminating outpatient professional services, or chemical dependency treatment. (Updated 7/2010)
     
  12. Behavioral Health Outpatient and/or Chemical Dependency Interval Treatment PlanFor Behavioral Health Providers only. Complete this form when more than 15 hours of outpatient professional sessions or continuing chemical dependency services are needed.  Do you need help filling out this form? See instructions of how to fill it out. (Updated 12/2013)
     
  13. Outpatient Psychological Testing Request: For Behavioral Health Providers Only. Complete this form to request outpatient professional psychological or neuropsychological testing. (Updated 7/2010)