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Access key forms for authorizations, claims, pharmacy and more.
Use this form to appoint an individual to act as a representative.
Use this form to file an appeal or dispute based on a claim outcome.
DME Authorization Request Form
Drug Prior Authorization Requests Supplied by the Physician/Facility
Requests for prior authorization (with supporting clinical information and documentation) should be sent to ʻOhana 14 days prior to the date the requested services will be performed.
Telemedicine Authorization Request Form
Behavioral Health Service Request Form
Refund Check Information Sheet* (RCIS)
Drug Prior Authorization Requests Supplied by the Physician/Facility
Request for Review of Medicare Prescription Drug Denial
