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Forms


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


  1. 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.  
     
  2. Provider Complaint: File a complaint with AlohaCare about our services or our members. 
     
  3. 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.
     
  4. Address/Contact Update/Change FormChange addresses or contact information.
     
  5. Referral/Prior Authorization/Notification Request: Refer your patients to specialists or request authorization for services/procedures on the prior authorization list.
     
  6. Drug Coverage Request: Request coverage for drugs that are not included on our formulary or require prior authorization. 
     
  7. Request for Addition/Deletion of Medication to Formulary: Explain why drugs should be added or deleted from our formulary. 
     
  8. 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. 
     
  9. Notification of Termination of Behavioral Health TreatmentFor Behavioral Health Providers Only: Complete this form when terminating outpatient professional services, or chemical dependency treatment.  
     
  10. Behavioral Health Outpatient and/or Chemical Dependency Interval Treatment PlanFor Behavioral Health Providers only. Complete this form when more than 1hours 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. 
     
  11. Outpatient Psychological Testing RequestFor Behavioral Health Providers Only. Complete this form to request outpatient professional psychological or neuropsychological testing.  
     
  12. Drug Coverage Request for Anti-Obesity AgentsRequest coverage for drugs related to anti-obesity agents.
     
  13. Pain Medication AgreementComplete this form with your patient when prescribing pain medication.
     
  14. Drug Coverage Request for Oxycodone: Request coverage for drugs related to pain management and oxycodone.

  15. Begin the process of joining AlohaCare’s Provider Network by completing the appropriate provider profile
    Behavior Health Provider Profile Form
    Facility & Ancillary Provider Profile Form 
    Physician Assistant Provider Profile Form
    Primary Care Provider Profile Form 
    Specialist Provider Profile Form