Printable Forms

Instructions

Forms on this page are in fillable-PDF format. In order to expedite registration and processing at your next appointment:

Fill out the appropriate form using your web browser.
Print the form.
Bring the completed form to your next appointment. DO NOT SUBMIT YOUR FORM via email.

Patient Registration Forms

Forms required to establish care in our clinic. Complete the appropriate form according to the service you will be receiving at your upcoming appointment.

MEDICAL SERVICES Registration Form (PDF) DENTAL SERVICES Registration Form (PDF) DENTAL SERVICES Health Information Form (PDF) BEHAVIORAL HEALTH SERVICES Registration Form (PDF)

Patient Forms

Important documents for current and new patients, including the Patient Handbook and Notice of Privacy Practices. These forms explain your rights, responsibilities, and how we protect your information.

Authorization Form 4A gives HLH permission to share specific information with another entity.

Authorization Form 4C gives other entities permission to share specific information with HLH.

PATIENT HANDBOOK (PDF) HIPAA Notice of Privacy Practices – Form 2A (PDF) Authorization to RELEASE Information FROM Hoʻōla Lāhui Hawaiʻi (Form 4A) (PDF) Authorization to RELEASE Information TO Hoʻōla Lāhui Hawaiʻi (Form 4C) (PDF)

Hoʻōla Cares Program (Sliding Fee Scale)

Select the form that applies to you and your family/household. Forms are separated by service and income level. More information about the Hoʻōla Cares Program can be found here

MEDICAL SFS A–D Form (PDF) MEDICAL SFS E Form (PDF) DENTAL SFS B–E Form (PDF) DENTAL SFS F Form (PDF) PHARMACY SFS A–D Form (PDF) PHARMACY SFS E Form (PDF) LABS & X-RAYS SFS A–D Form (PDF)

Employment Application Forms

Visit our Employment Opportunities page to see which positions are currently hiring. Download the Employment Application, complete the application, and send a copy to the HR Director at jashby@hoolalahui.org.

EMPLOYMENT APPLICATION (PDF)