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For immediate assistance please contact Hawai i HIE at helpdesk hawaiihie. org or 808 441-1373. NOTE Completing this form as a fillable PDF ensures the information you provide is legible and this will enable faster processing. Mahalo Practice Information Legal Name of Entity Phone Address City State Zip Code Provider/Staff Information Add Remove DOB POC DSA NPI State License Specialty/Title Email Address Services Requested Referrals CHR DSM Practice Liaison Name Please print first and last...
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