Patient Forms
To help protect your personal health information, we recommend that patients submit forms through MyChart, our secure online patient portal, whenever possible. MyChart offers the safest and most efficient way to send documents directly to your care team
If you are unable to use MyChart, you may also:
- Email our Medical Records team to request forms at medical.records@HICHC.org
- Call 808-333-3600 for help with your request
Below are the names of our most frequently requested patient forms for your reference:
- New Patient Packet (Adult or Child)
- To register as a new HICHC patient
- Minor Power of Attorney
- Parents/legal guardians may complete this form to allow other trusted caregivers to make medical decisions for a child.
- Release of Information Request (ROI)
- Authorizing sharing of your medical information with a specialist, provider, or loved one.
- Sliding Fee Scale Application
- Apply for HICHC’s Sliding Fee Discount by providing household and income information
- Ground Transportation Request
- Complete to request help with transportation to appointments or care
- Air Transportation Request
- Complete to request help with air travel to receive care off island
- MyChart Proxy Request (Adult or Child)
- Complete to share MyChart record access with a trusted loved one