Original Effective Date:
08/01/1994
Current Effective Date:
01/01/2015
The first column of the table below contains links to documents that describe or otherwise refer to the listed forms. The second column contains links to the actual forms.
Forms are in PDF format. You can view them using Adobe Reader or another PDF-reader application. Most forms can be completed directly on your computer and then printed for faxing or mailing to HMSA.
| Description, Instructions, and Other Information | Link to Form | Provider Type(s) |
|---|---|---|
| Agent Authorization | Multiple | |
| Agreement of Financial Responsibility | Multiple | |
| QUEST Integration (QI) Plans Bone Density Studies | Medical | |
| Care Navigation Referral Form | ||
| Long-Term Services and Supports (LTSS) Referral Form | Form [PDF] | |
| Magellan Hawaiʻi, PCP Referral Form | Form [PDF] | Behavioral Health |
| QUEST – Early and Periodic Screening, Diagnosis and Treatment (EPSDT) | Medical | |
| QUEST Integration Formulary Exception Criteria Fax Form | Form [PDF] | Pharmacy |
| QUEST Integration Health Coordination Services Referral Form | Form [PDF] | Medical |
| QUEST Integration – Home Health Assessment Form | Form [PDF] | Medical |
| QUEST Integration – Hysterectomy (Form is required for services provided prior to 06/03/2020) | Form [PDF] | Medical |
| QUEST Integration – Instructions for Completing CMS 1500 Claim Form | Form [PDF] | Medical |
| Precertification/Prior Authorization Request – Hemophilia A and B Blood Products | Form [PDF] | Medical |
| Precertification/Prior Authorization Request – QUEST Integration | Medical | |
| Provider Information Forms | Multiple | |
| QUEST Integration – Sterilizations | Form [PDF] | Medical |
| Vision |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform.
|