Application Form Physician InformationPhysician Name CredentialsSelect CredentialsANPAPAPRNDODPMFNPMDNDNPODPAPharmDPhDPsychDPTRNOther PCP or SpecialistSelect PCP or SpecialistPCPSpecialistUrgent Care ONLY PCP or Specialty TypeGeneral PracticeInternal MedicineFamily PracticePediatricsAddiction MedicineAdolescent MedicineAllergy & ImmunologyAllied Health ProfessionalAllopathic & OsteopathicAnesthesiaCardiology/Cardiovascular DiseaseCritical CareDermatologyEmergency MedicineEndocrinologyFertilityGastroenterologyGeriatric MedicineGynecologic OncologyGynecologyHematologyHepatologyHospice & Palliative MedicineHospitalistInfectious DiseasesMaternal/FetalMedical GeneticsNeonatologyNephrologyNeurological SurgeryNeurologyObstetrics and GynecologyOncologyOphthalmologyOptometryOrthopedic SurgeryOtorhinolaryngologyPain ManagementPathologyPhysical Medicine/RehabilitationPlastic SurgeryPodiatryPreventative MedicinePsychiatryPsychologyPulmonary DiseasePulmonologyRadiation 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 Number Affiliation with Clinic Select Affiliation with ClinicOwnerEmployedContracted 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 Email Preferred Contact MethodSelect Preferred Contact MethodEmailFaxIn-PersonMailPhoneText 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/EMRAcumenADPAllmedsAllscripts/Team PraxisAmazing ChartsAprimaAthena HealthAzalea HealthCare360Care CloudCatalisCentricityCernerChartLogicConnect CareLinkCPSICureMDDigiDMSDr. ChronoDRS enterpriseeClinicalworksElationEMDsEpicEpic HPHEpic QueensEmaGE CentricityGenixgMed gGastroGreenwayIntellechartiMDio PracticewareIsalisMaximEyesMcKessonMedflowMeditechMediTouchMedXOpenMicroMDModernizing MedicineMTBCNextGenNextTecNuesoftOfficeMateOncoEMROnline AffiliateOpenEMROptumPoint & ClickPowersoftPractice FusionRadekalRxNTSoapWareSpringChartsSRS SoftTraknet PMViteraN/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 gPMGreenwayHealthpacIsalisMcKessonMedFMMedisoft 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 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 (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 Tax ID Number 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 Billing SystemSelect Billing SystemInside BillerOutside BillerBilling Company 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 participated in a Patient Centered Medical Home Program? Where, when? 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 julie@hawaiiipa.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.
