Become A Patient

Thank you for your interest in Wellness Partners Hawaii, Inc. We welcome the privilege of participating in your care and will do everything possible to make your experience with us a positive one.

The following form/checklist is provided to ensure a smooth transition into our practice. You should check ALL the boxes. If you do not meet any of the requirements and would like to discuss further, please text our office at 808.379.6656 or email our office at info@wellnesspartnershawaii.com.

Mahalo for for taking your time to complete this form!

First Name

Last Name

Phone Number

Your information is of utmost importance to us. Your number will never be shared with any third party or used for marketing purposes. To opt-in SMS communication with Wellness Partners Hawaii for administrative assistance (scheduling/prescription refill request/billing etc.) please type
OPT IN below. To opt-out, please type OPT OUT.

Date of Birth

Address

City, State

Zipcode

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relationship

Emergency Contact Phone Number

I live and reside in the state of Hawai‘i.

Our providers are licensed in the state of Hawaii. In accordance to telehealth laws, we can only serve those who are physically in the state of Hawaii.

I am comfortable with telehealth visits

I have access to stable high-speed Internet and smart devices to conduct video calls

Per insurance requirements, our providers will need to be able to see you via video.

I have one or more of the following insurance coverage:

In-Network with WPH

AlohaCare QUEST

Blue Cross Blue Shield

HMSA PPO / HMO / Akamai / QUEST

HMAA (Hawaii Management Alliance Association)

HMA (Hawaii Mainland Administrators)
Medicare

Ohana QUEST

Tricare West Prime & Select

UHA (University Health Alliance)

VA CCN (Veterans Affairs Community Care Network)

Out of Network with WPH

Aetna

Cigna

United HealthCare / Optum

Primary Insurance Front

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Primary Insurance Back

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Secondary Insurance Front

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Secondary Insurance Back

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Photo ID (for insurance verification purposes)

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I will self pay if I don't have one of the above insurance coverage or I have gaps in coverage

I am not active duty military

If you are active duty military, please contact your primary care manager to obtain a referral / authorization.

I am not requesting for benzodiazepines OR I am looking to taper off of benzodiazepines

We are a benzodiazepine (Ativan, Xanax, Valium, etc.) free clinic and it is our office policy not to prescribe them.

If I saw a therapist, nurse practitioner or psychiatrist previously I am willing to sign a release of information form for record request

What mental health concerns are you looking to address

Additional Questions / Provider Preferences / Appointment Date & Time Preferences

How did you hear about Wellness Partners Hawaii Inc.?