Required Documents

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Click HERE or on the box below to access all of the required items and documents that need to be submitted at least 10 BUSINESS DAYS prior to youth's admittance to treatment.

Please submit all items/documents via fax:

Fax # (808) 293-7196

Attention: Andrea Nakashima or Andrea Tuialuuluu

Failure to submit any of the following will result in a delay in the youth's admission and may even result in the youth being placed on a waiting list.

INTAKE & MEDICAL FORMS

Required Items

Copy of youth's Birth Certificate

CAFAS-5 Scale (CAMHD youth only)
Coordinated Service Plan (CSP) (CAMHD youth only)
Copy of youth's medical/dental card(s)
Copy of youth's ID card (If available)
School IEP (if applicable)
Any pertinent legal documents
Any other updates pertaining to the youth that may affect their treatment (i.e. changes to their physical/mental health or legal situation)

Checklist PDF

Access the Medical and Intake Forms HERE

PHYSICAL EXAM: Documentation completed by a Physician of the youth's Physical Exam. The exam must have a full review of systems and be signed and dated by the Physician. Date of the exam must be within one year of the date of youth's admission to Bobby Benson Center. If physical has expired prior to youth's date of admission to Bobby Benson Center they will need to see a physician to obtain a current physical exam.

TB: TB clearance dated within one (1) year of admissions date at Bobby Benson Center. TB clearance must include induration results and be signed and dated by the medical professional administering and reading the test results. TB tests that come back as positive must have clearance by the State of Hawaii's TB branch prior to being admitted to the center.

PRESCRIPTION & MEDICAL HISTORY FORM: Prescriptions and Medical History page one (1) is for the Legal Guardian to sign, Page (2) is for the prescribing physician, psychiatrist or other prescribing medical professional to sign. If youth does not currently take prescription medication then please indicated on the form not currently taking any prescribed medications.

MEDICAL HEALTH AND DENTAL INSURANCE FORM: Please ensure to fill out both Medical and Dental Insurance information in its entirety as this will prevent delays in your youth

Changing Primary Care Physician

It is also recommended that all youth who have MedQuest (such as HMSA Quest and AlohaCare Quest) switch Primary Care Physicians to Dr. Marc B Shlachter

This will help to ensure the youth is able to receive medical care without delays. Unfortunately Bobby Benson Center cannot do this change, only the Legal Guardian can call their insurance provider and request that the Primary Care Physician be changed.

ALOHA CARE QUEST

To change your primary care provider (PCP) with AlohaCare, you can complete the PCP Change Form:

Online: Complete the PCP Change Form
By mail or fax: Complete the PCP Change Form and mail or fax it to 1357 Kapiolani Blvd., Ste G101, Honolulu, HI 96814, or fax it to (808) 973-3810

You can also call AlohaCare customer service at (808) 973-0712 or toll-free at (877) 973-0712. TTY users can call (877) 447-5990.

HMSA QUEST

If you would like to change your PCP, please submit an online request by using our secure web form Ask HMSA. The form is available through your HMSA My Account at hmsa.com. Once you log in, select Ask HMSA in the Help Center box or under your Profile.

If you are unable to submit an online request, you may contact HMSA Customer Relations on Oahu at 808-948-6372 or 1-800-776-4672.

You may also mail your request to:

Health Plan Hawaii
Customer Relations Department
HMSA
P.O. Box 860
Honolulu, HI 96808-0860