Get Hi West Maui Counseling Center Registration Form 2013-2025

Filling out the HI West Maui Counseling Center Registration Form online is an important step in accessing the services provided by the center. This guide will help you through the process, ensuring you complete each section accurately and efficiently.

Follow the steps to successfully complete your registration form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your primary care physician's name and today’s date at the top of the form. This information establishes your connection to medical care.
3. Proceed to the 'Patient Information' section. Fill in your last name, first name, and middle name. Verify that the name you use is your legal name. If applicable, provide any former names as well.
4. Indicate your marital status by selecting one of the options: single, married, divorced, or separated. Then, enter your birth date and age.
5. Next, provide your social security number and your current address, including street, city, state, and ZIP code. This ensures accurate identification and communication.
6. Fill in your occupation and employer details, then enter your cell phone number and home phone number. Ensure all information is accurate for reliable contact.
7. In the section labeled 'Chose clinic because/referred to by,' check the appropriate box that reflects your reasons for visiting the clinic.
8. Provide your email address and indicate whether you would like to receive appointment reminders via email.
9. Move to the 'Insurance Information' section. If you have insurance, please ensure you have your insurance card ready to provide to the receptionist. If you are the insurance subscriber, fill in the subscriber's name, birth date, and relationship to the subscriber.
10. If you are not the subscriber, fill out the details of the person responsible for the bill and their insurance information as required. Be sure to list any secondary insurance if applicable.
11. In case of an emergency, provide the name, relationship, and contact numbers for a local friend or relative.
12. At the end of the form, confirm the accuracy of the information. Sign the form as the patient or guardian and date it to authorize the submission of your information.
13. Finally, save any changes made to the form. You may download, print, or share the completed registration form as needed.

Complete your registration form online today to start accessing the services you need.