Referral Form for Providers in Honolulu, HI

Thank you for submitting a referral!

Please download, complete, and fax the below referral form to (808) 556-0100.

Please be sure to include the patient demographics, additional supporting physician notes that discuss medical nutrition therapy necessity, and labs (CMP, lipids, vitamin D, iron, thyroid, A1C if applicable) as they are required for medical nutrition therapy.

I currently take the following insurance plans: HMSA, UHA, Medicare, HMAA, and Tricare. Cash rates also available.

*If your patient has HMSA, covered diagnoses for medical nutrition therapy include overweight, obesity, and hypertension. Anything outside of the covered diagnoses would require prior authorization. View HMSA’s policy of covered diagnoses here.

*If your patient has Medicare, covered diagnoses for medical nutrition therapy are only diabetes and chronic kidney disease.

If you haven’t heard back for an initial appointment within 2 weeks of forms submission, please contact our office directly at (808)556-0100.