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Access key forms for authorizations, claims, pharmacy and more.

Appeals & Grievances

Use this form to appoint an individual to act as a representative.

Use this form to dispute a provider payment.

Use this form to file an appeal or dispute based on a claim outcome.


Requests for prior authorization (with supporting clinical information and documentation) should be sent to  ĽOhana 14 days prior to the date the requested services will be performed.

Telemedicine Authorization Request Form


Refund Check Information Sheet* (RCIS)

Medical Records


Other Provider Forms


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Last Updated On: 2/4/2019