Form Instructions
The Good Pregnancy – He Hapai Pono Member Enrollment Form
To become a member of this program at no cost, please print and fill out this form.
Submit it to He Hapai Pono.
To avoid delays, please make sure your application is complete.
- Fill in your name, birth date, address, telephone numbers, email address, and HMSA number.
- Tell us when we may call you to arrange an appointment and which number you’d like
us to call.
- Provide your OB care provider’s name, location and telephone number.
- Indicate your due date and if you’re currently receiving prenatal care.
- Sign and date the form.
- Submit this form with your Permission to Share Medical Information form.
Fax or mail all materials to:
He Hapai Pono
1600 Kapiolani Blvd., Suite 920
Honolulu, HI 96814
Fax: 1 (800) 952-4460