Provider Contact Change Form - Hawaii Department of Health 2026

1. Click ‘Get Form’ to open the Provider Contact Change Form in our platform.
2. Begin by entering your Agency Name and the Date at the top of the form. This information is essential for identifying your submission.
3. Specify the Type of Service(s) provided by your agency, ensuring clarity on what services are affected by this change.
4. Fill in the Contact Name & Telephone Number for direct communication regarding this change.
5. Indicate the Action to be taken (Add, Change, or Close) and provide the Effective Date of Action.
6. Complete the Old Location Address and New Location Address fields, including the 4-digit zip code extension for accuracy.
7. Answer whether the New Location Address is your Agency’s Primary Business Location and provide details if it is not.
8. If applicable, indicate if this is a Mailing Address Change and attach any necessary documentation as specified.
9. Provide both Old and New Telephone/Facsimile Numbers to ensure updated contact information.
10. Sign and date the form at the bottom before mailing it to the specified address for processing.

Start using our platform today to easily complete your Provider Contact Change Form online for free!