Forms and Resources

Downloadable Forms and Resource Materials

• 2024 Annual Health Assessment Form
• 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, 2023.
  *Note: Conifer will be honoring the 2023 MDX Prior Authorization List (PAL) requirements until a
  2024 PAL becomes available. More information will be provided in the upcoming months on Cap
  Connect.
• MDX Hawai‘i's Prior Authorization Request Form (Rev. 01/2024)
  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 HMO Specialty Referral Request Form (Rev. 1/2024)
  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.
• Office Practice Information Form (Rev. 01/2024)
  This form is to be filled out for new practices.
• Online Access Registration Form for Master Administrator User Account
  This form needs to be filled out if you need to reset an account password, or create an account for Hawaii's Core portal to check or submit any 2023 claims please fill out this form.
• Palliative Care Referral Form
  This form is used to refer your patient for Palliative Care services by MDX Hawai‘i.
• Provider Demographic Update Form – Individual (Rev. 01/2024)
  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. 01/2024)
  This form is used by contracted groups or facilities to update information on an existing provider record.
• W-9 Form