Application - Hawaii IPA

Provider Information

Provider Name

Provider DOB

Credentials

Supervising PCP(APRN/PA/ND)

PCP or Specialist

If your specialty is not listed,
please list it here

NPI (Individual)

NPI (Group/Practice)

Tax ID Number

Legal Business Name

Clinic Ownership

Please specify

Affiliation with Clinic

Email

Preferred Contact Method

Facilitating Patient Care

Practice Information

Practice Name

Street Address

City

State

Zip/Postal Code

Country

Island

EHR/EMR

If your EHR/EMR is not listed,
please list it here

Practice Management System

If your PMS is not listed,
please list it here

Office Hours

Phone

Fax

Website

Office Contact Full Name

Office Contact Job Title

Office Contact Phone Number

Office Contact Email

Is this practice location the same as your mailing/billing address?

Mailing Street Address

Mailing City

Mailing State

Mailing Zip/Postal Code

Mailing Country

Other Practice Locations

Additional Practice Location 1 Name

Address (1)

City (1)

State (1)

Zip Code (1)

Phone # (1)

Fax # (1)

Additional Practice Location 2 Name

Address (2)

City (2)

State (2)

Zip Code (2)

Phone # (2)

Fax # (2)

Additional Practice Location 3 Name

Address (3)

City (3)

State (3)

Zip Code (3)

Phone # (3)

Fax # (3)

Additional Practice Location 4 Name

Address (4)

City (4)

State (4)

Zip Code (4)

Phone # (4)

Fax # (4)

Additional Information

Please note, all applicants are subject to Membership Committee review and approval prior to participation. Prior to membership review, all applicants must be fully credentialed or in-process of being credentialed. Once an applicant has been reviewed, a follow-up email will be sent from our Administration Team with the Membership Committee’s decision and next steps.

Are you applying to participate in HMO with Hawaii IPA?

(PCPs only) Are you applying to participate in a value-based program with Hawaii IPA?

Please check all that you would like to apply for:

HMSA Payment Transformation

MDX Risk Adjusted Capitation Program (RACP)

ACO REACH

Additional Information

If your specialty is not listed,
please list it here

Please specify

Vacation Coverage Policy

If your EHR/EMR is not listed,
please list it here

If your PMS is not listed,
please list it here

Other Office Information

Full Name(s)

Email Address(es)

Phone Number(s)

Front Desk Staff

Medical Assistants/Nurses

Admin/Office Manager

Midlevels/Nurse Practitioners

Previous Quality Programs/Organizations

Have you previously reported Physician Quality Reporting System (PQRS)? Which years?

Have you previously reported Meaningful Use? Which years?

Have you previously participated in a Patient Centered Medical Home Program and/or HMSA's Payment Transformation? Where, when, under what PO?

Have you participated in an Accountable Care Organization? Where, when?

Other Information

Have you previously held membership in an Independent Physician Association (IPA)? If so, which one?

Highest Degree Obtained, School Name, Year, etc.

Post Graduate Training (e.g. Internship, Residency, Other)

Hospital Affiliations

START TYPING AND PRESS ENTER TO SEARCH