Forms and Resources

Downloadable Forms and Resource Materials

• 835 Health Care Electronic Remittance Advice (ERA Request Form)
  This form is used when a provider wants to receive electronic remittance advice from MDX Hawai‘i.
• Behavioral Health/Medical Provider Communication Form
  This form allows the Primary Care Physician and Behavioral Health Provider to share appropriate treatment information with each other to ensure continuity and coordination of care for Medicare Advantage Plan members. We encourage you to use this form to obtain a signed release from your patient who is a Medicare Advantage Plan member.
• Care Coordination Referral Form
  This form is used to refer your patient for Care Management services by MDX Hawai‘i. 
• Hawai‘i Specialty Pharmacy Request Forms
  To request specialty medications, please click on the link above to obtain the appropriate form.
• MDX Hawai‘i Medicare Advantage Plans Provider Reconsideration Form
  This form is used to initiate a Provider Reconsideration Request for Medicare Advantage Plans.
• MDX Hawai‘i's Prior Authorization List for Medicare Advantage Plans
  This is a list of the services that require prior authorization effective January 1, 2021.
• MDX Hawai‘i's Prior Authorization Request Form (Rev. 10/2018)
  This form is used to obtain approval for medical services and drugs that are listed on MDX Hawai‘i's Prior Authorization List for Medicare Advantage Plans. Please complete this form and fax it to MDX Hawaii at (808) 532-6999 on O‘ahu, or 1-800-688-4040 toll-free from the Neighbor Islands.
• MDX Hawai‘i's Specialty Referral Request Form (Rev. 10/2018)
  This form is used when requesting a referral for Participating Specialist or Specialty Care for HMO members only. Please complete this form and fax it to MDX Hawai‘i at (808) 532-6999 on O‘ahu, or 1-800-688-4040 toll-free from the Neighbor Islands.
• Online Access Registration Form for Master Administrator User Account
  This form allows you to appoint a "Master Administrator User" account to manage users and accessibility to MDX Hawai‘i's secure provider sections.
• Office Practice Information Form (Rev. 02/2022)
  This form is to be filled out for new practices.
• Provider Demographic Update Form – Individual (Rev. 02/2022)
  This form is used by contracted individual practices (sole practitioners) to update information on an existing provider record.
• Provider Demographic Update Form – Group Facility (Rev. 02/2022)
  This form is used by contracted groups or facilities to update information on an existing provider record.
• W-9 Form