Become a Patient

Please complete the form below. You will be contacted within 3 business days to complete a brief phone intake.

If you are actively having suicidal ideation, thoughts of self-harm,

or thoughts to hurt others, please stop now and call 911 or your local crisis team.

Which of the following are you?: (Select one only)

Adult Patient (18 or older)

Parent of minor (17 or younger)

Legal guardian of patient (Must submit legal form below)

Power of Attorney (Must submit legal form below)

Patient Name

(Legal first and last name, as it appears on your Insurance):

First name (Patient's)

Last name (Patient's)

Date of Birth (Patient's)

Parent/Guardian Name

(Legal first and last name if appointment is for a minor 17 and under):

First name

Last name

Phone

May we call and leave a voicemal and/or email at the above listed phone number and email?

Yes

Did someone refer you to our practice? If so, who?

Yes

Do you have a provider preference regarding who you see at West Oahu Mental Health? If so, who?

Yes

Accepted Insurance Plans

Alohacare Quest (Medicaid)

Alohacare Advantage (Managed Medicare)

AARP

Cigna (MDX)

HMSA Quest (Medicaid)

HMSA Akamai (Managed Medicare)

HMSA PPO

HMSA HMO

HMSA Federal

HWMG/HMAA

Hawaii Senior Medical Group

Humana (MDX)

Ohana Quest (Medicaid)
Ohana Advantage (Managed Medicare)

Medicare B

MDX

Tricare West Region

United Healthcare Quest (Medicaid)

United Healthcare Advantage (Managed Medicare)

United Healthcare PPO

UHA

Please list which of the above Insurance plans you have:

I declare that I live and reside on the island of Oahu.

I am not in a active duty military status.

What mental health concerns would you like to address?

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