Application Form

For HMO applicants, additional paperwork is needed to complete your application once your application is submitted below.

  1. HMO Attestation: please download, sign, and email to upon submission of your application
  2. HIPA Anti-Trust P&P: please download, sign, and retain for your records a copy of HIPA's anti-trust Policy and Procedure
Physician Information
Facilitating Patient Care
Practice Information
Other Practice Locations
Additional Information
Other Office Information
# of Staff/Name
Contact Information
Previous Quality Programs/Organizations
Other Information
Please send a copy of your most recent CV to HIPA at Please note: your application will not be complete until the CV is received.

Please Note: The Membership Committee meets every odd-numbered month and will review all new applications at that time.

After receiving approval from Membership Committee, HIPA will set up a meeting to go over Membership Compacts & Contracts. There is a 6-month probationary period for all new members. The committee will reconvene to discuss the new member at the 6-month mark. Please call HIPA at (808) 524-4041 if you have any questions.