Forms and Documents

Questions? Contact Customer Services (808) 532-4000, or toll free 1 (800) 458-4600 8 a.m. - 5 p.m. Hawaii Standard Time Monday through Friday except holidays

Member Forms

Accident Information Form

PDF Document

Express Scripts National Preferred Formulary and Exclusions List 2022

PDF Document

HIPAA Authorization for Release of Information

PDF Document

Express Scripts National Preferred Formulary and Exclusions List 2023

PDF Document

Lab Services

PDF Document

Notice of Privacy Practices

PDF Document

Procedures That Are Considered Cosmetic

PDF Document

Request HDS Subscriber ID Card

External Link

Request UHA Member ID Card

PDF Document

TCOYD Conference Reimbursement Form

PDF Document

Services That Require Prior Authorization

PDF Document

Appeals Documents

Authorized Representative Form

PDF Document

Disclosure for Conflicts of Interest Evaluation

PDF Document

External Review HIPAA Authorization Form

PDF Document

How To Initiate An Appeal

PDF Document

If You Disagree With Our Final Decision

PDF Document

Request for External Review by IRO

PDF Document

Out-of-State Services

Medical Travel Checklist

PDF Document

Notice to Members Regarding Out-of-State Services

PDF Document

CAUTIONARY NOTICE to Members Regarding Out-of-State Lab Services

PDF Document

Member Quick Guide

PDF Document

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