Application Application Form For HMO applicants, additional paperwork is needed to complete your application once your application is submitted below. HMO Attestation: please download, sign, and email to firstname.lastname@example.org upon submission of your application HIPA Anti-Trust P&P: please download, sign, and retain for your records a copy of HIPA's anti-trust Policy and Procedure Physician InformationPhysician Name Provider DOB CredentialsSelect CredentialsANPAPAPRNDODPMFNPLCSWMDNDNPODPAPharmDPhDPsychDPTRNOther Supervising PCP(APRN/PA) PCP or SpecialistSelect PCP or SpecialistPCPSpecialistUrgent Care ONLY PCP or Specialty TypeGeneral PracticeInternal MedicineFamily PracticePediatricsAddiction MedicineAllergy & ImmunologyAllied Health ProfessionalAllopathic & OsteopathicAnesthesiaCardiology/Cardiovascular DiseaseCertified Nurse MidwifeCritical CareDermatologyEmergency MedicineEndocrinologyFertilityGastroenterologyGeriatric MedicineGynecologic OncologyGynecologyHepatologyHospice & Palliative MedicineHospitalistInfectious DiseasesMaternal/FetalMedical GeneticsNeonatologyNephrologyNeurological SurgeryNeurologyNuclear MedicineObstetrics and GynecologyOncology/HematologyOphthalmologyOptometryOrthopedic SurgeryOtorhinolaryngologyPain ManagementPathologyPhysical Medicine/RehabilitationPlastic SurgeryPodiatryPreventative MedicinePsychiatryPsychologyPulmonologyRadiation OncologyRadiology, DiagnosticRadiology, NuclearRheumatologySleep MedicineSports MedicineSurgery, CardiacSurgery, Colon and RectalSurgery, Foot/AnkleSurgery, GeneralSurgery, Hand/WristSurgery, ThoracicSurgery, VascularUrologyUrgent Care OnlyOther/Not Listed If your specialty is not listed, please list it here NPI (Individual) NPI (Group/Practice) Primary Provider Organization CastleCentral MedicalEHIHFHHIPAHPHHQPOKaiser/ MHSKauaiMary SavioMMGOPG/WHIP/5 MTNPMAGQueensSt. Francis Other Organization Affiliations CastleCentral MedicalEHIFilipino Health GroupHawaii Health PartnersHFHHIPAHPHHQPOKaiser AdvantageKauaiMary SavioMMGMIKOOPG/WHIP/5 MTNPacific Health CarePMAGQueensSt. FrancisStraub Tax ID Number Clinic Ownership Select Clinic OwnershipPhysician(s) (Clinic Owned by 1 or more physicians)Health System (i.e. Queens, HPH, Castle, Kaiser)University of HawaiiFacility (i.e. DaVita)FQHCEmployer GroupHealth Plan (i.e. Humana Clinic)HHSC CorpOther Affiliation with Clinic Select Affiliation with ClinicOwnerEmployedContracted Email Preferred Contact MethodSelect Preferred Contact MethodEmailFaxIn-PersonMailPhoneText Practice DetailsMDX RACP Participant Facilitating Patient CareAccepting New Patients? If yes, please select which lines of business. AetnaAlohaCareCignaHMSA CommercialHMSA QuestHMSA AkamaiHMAHMAAHumanaKaiser Added ChoiceMedicaidMedicareMDXOhanaTricare WestUnion InsuranceUHAUHCNot accepting new patients Practice InformationPractice Name Street Address City State Zip/Postal Code Country IslandSelect IslandOahuMauiKauaiHawaii (Big Island)LanaiMolokai EHR/EMRSelect EHR/EMRAcumenADPAdvancedMDAllmedsAllscripts/Team PraxisAmazing ChartsAprimaAthena HealthAzalea HealthCare360Care CloudCatalisCentricityCernerChartLogicConnect CareLinkCPSICureMDDigiDMSDr. ChronoDRS enterpriseeClinicalworksElationEMDsEpicEpic HPHEpic QueensEmaGE CentricityGenixgMed gGastroGreenwayIntellechartiMDio PracticewareIsalisKareoMaximEyesMcKessonMedflowMeditechMediTouchMedXOpenMicroMDModernizing MedicineMTBCNextGenNextTecNuesoftOfficeMateOncoEMROnline AffiliateOpenEMROptumPoint & ClickPowersoftPractice FusionRadekalRxNTSoapWareSpringChartsSRS SoftTraknet PMVarianViteraN/A: Do not use EHR/EMREHR/EMR not listedConfidential If your EHR/EMR is not listed, please list it here Practice Management SystemSelect Practice Management SystemAdvanced MDAkamaiAllmedsAmazing ChartsAprimaAthena HealthCare CloudCatalisCernereClinicalworkseMDsEpicGE CentricitygMed gPMGreenwayHealthpacIsalisKareoMcKessonMedFMMedisoft BillingMedisolMedix BillingMicrodyne Medical ManagerNextGenPoint & ClickRCISoapwareTeam PraxisPMS Not listedN/A (none) 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? Select Yes or NoYesNo Mailing Street Address Mailing City Mailing State Mailing Zip/Postal Code Mailing Country Mailing Address 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) Other Internal InfoMDX RACP Start Date Contracts on FileMDX RACP PPA w HIPA Additional Information (PCPs only): Are you applying to participate in Payment Transformation through Hawaii IPA? Select Yes or NoYesNo Additional Information If your specialty is not listed, please list it here Preferred Urgent CareAloha Critical Care AssociatesBraun Urgent Care, KailuaConcentra Urgent Care, HonoluluDoctors on Call, Maui-LahainaDoctors on Call, StraubDoctors on Call, WaikikiHoala Urgent CareIsland Urgent Care, Hawaii KaiIsland Urgent Care, KakaakoIsland Urgent Care, KapahuluIsland Urgent Care, KahalaKalihi Kai Urgent CareKihei Wailea Urgent Care, MauiKuhio Walk-in ClinicKunia Urgent CareMinit Medical Urgent Care, KahuluiMinit Medical Urgent Care, LahainaMinute Clinic, AieaMinute Clinic, King StreetMinute Clinic, WahiawaMinute Clinic, WaikikiQueens After Hours Pediatric ClinicThe Medical Cornder, AirportThe Minute Clinic, KaneoheUrgent Care Clinic of WaikikiUrgent Care Hawaii, KailuaUrgent Care Hawaii, KapoleiUrgent Care Hawaii, Pearl CityUrgent Care Hawaii, WaikikiUrgent Care West MauiWaimea Urgent CareWindward Urgent CareOTHER 24/7 Access Answering ServiceDirect Line to PhysicianHMSA Online CarePhysicians ExchangeOnline Platform via Provider's EMROther 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 # of Staff/NameContact Information Front Desk Staff Medical Assistants/Nurses Admin/Office Manager Midlevels/Nurse Practitioners Previous Quality Programs/Organizations Have you previously reported 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? Medical School Attended, Years, Degree Obtained? Residency Program Hospital Affiliations ResumePlease send a copy of your most recent CV to HIPA Administrator Julie Warech at email@example.com. Please note: your application will not be complete until the CV is received. Captcha 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 Administrator Julie Warech at (808) 524-4041 if you have any questions.