This form is not for urgent medical matters. If you need urgent medical attention, call 911.

If you need help from a case manager, please call us at (808) 397-3595.

Please do not include any protected health information (PHI) in this form.

  • Phone
    (808) 397-3595
  • Fax
    (808) 638-3435
  • Address
    PO Box 37352
    Honolulu, HI 96837