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Human Services Hawaii.gov

Fee-For-Service

New providers are required to complete a Medicaid Provider Application/Change Request Form (DHS 1139 Rev 02/14) to enroll as a provider in the Medicaid Fee-For-Service (FFS) Program.

Existing providers are required to complete a Medicaid Provider Application/Change Request Form (DHS 1139 Rev 02/14) if there are any changes to the information.

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