Form Instructions
Disclosure for Conflicts of Interest Evaluation
- Please write in the right column the information that is being requested in the
left column.
- Sign your name below.
- Write today’s date.
Once you’ve filled out the form, please mail it with your request to:
Hawaii Insurance Division
Attention: Health Insurance Branch – External Appeals
335 Merchant St., Room 213
Honolulu, HI 96813
