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Provider Information
Facilitating Patient Care
Practice Information
Other Practice Locations
Additional Information
  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

Please note, all applicants are subject to membership committee review and approval prior to participation. The membership committee meets bi-monthly to review all applicants. Prior to membership review, all applicants must be fully credentialed with the payor selected. Click here to review our Membership & Contract Participation Definitions, Policies, and Procedures, which is subject to change.


Other Office Information
Full Name(s)
Email Address(es)
Phone Number(s)
Previous Quality Programs/Organizations

* If you participated in the HMSA PT program with another PO, click here to complete the required additional supplemental form required for application processing. You may email the forms, along with the CV, to
* If you previously participated in a capitated program with Hawaii IPA and are re-applying, click here for the required additional form for application processing. You may email the forms, along with the CV, to

Other Information