1115-26204 06/2018 Hospital Affiliations Provider name: HMSA provider number: National provider identifier (NPI): To help ensure the accuracy of HMSA’s provider directory information, which helps our members when choosing a PCP or specialist, please take a few moments to complete the information below. Check off any hospital or medical center you are affiliated with below: Adventist Health Castle fka Castle Medical Center Hale Hoola Hamakua fka Honokaa Hospital Hawaii Medical Center East Kohala Hospital Kahi Mohala Behavioral Health Kahuku Medical Center Kaiser Permanente Moanalua Medical Center Lanai Community Hospital Ka’u Hospital Kauai Veterans Memorial Hospital Kohala Family Health Center Molokai General Hospital Kona Community Hospital Kuakini Medical Center Kula Hospital Samuel Mahelona Memorial Hospital Leahi Hospital Maluhia Maui Memorial Medical Center The Queen’s Medical Center North Hawaii Community Hospital Pali Momi Medical Center Rehabilitation Hospital of the Pacific Other (please specify): _______________________ _______________________ _______________________ _______________________ Shriners Hospital for Children - Honolulu Spark M. Matsunaga Veterans Affairs Medical Center Straub Clinic & Hospital The Queen’s Medical Center – West Oahu fka Hawaii Medical Center West Tripler Army Medical Center Hilo Medical Center Wahiawa General Hospital Wilcox Memorial Hospital Kapiolani Medical Center for Women & Children If I have signed this Hospital Affiliation Form electronically, it means that I acknowledge and agree to the terms of this Hospital Affiliation Form and so indicate by typing my name below as my electronic signature, executed and adopted by me with the intent to sign this document. In other words, typing my name as an electronic signature indicates that I acknowledge and agree to the terms of this form just as a handwritten signature would on a paper form. Signature Date Printed or stamped name Social Security number (last four digits only) Please mail or fax this completed form to: HMSA Provider Data Administration – KLCR-PDA P.O. Box 860 Honolulu, HI 96808-0860 Phone: 952-7847 on Oahu 1 (800) 603-4672, ext. 7847, toll-free on the Neighbor Islands Fax: 948-8210 on Oahu Email: [email protected]