Hawaii Independent Physicians Association

HIPA Membership Application

First Name:

Middle Initial:

Last Name:

Other

Primary Care Physician:

Specialist (Area of Specialty):

List as Both:

Office Street Address (include Suite number):

City:

Island:

Zip Code:

Telephone:

Fax:

Email Address (will be kept confidential):

Name of Your Primary Office Manager:

Please provide three peer references:

Plan Affiliation: (You may affiliate with either or both of the following Health Plans through the Hawaii IPA. Please indicate below)

HMSA Health Plan Hawaii

AlohaCare