Forms

Select and download your Koʻolauloa Health Center form on this page.

Instructions: Please click on one of the images to download your desired Koʻolauloa Health Center Form.

If you have any questions, please call (808) 293-9231 for assistance.

Request Medical Records

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Consent to Electronic Communications

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Note: Koʻolauloa Health Center patients may request a copy of their medical records. Please complete all sections and submit the Consent to Release Confidential Information from Koʻolauloa Health Center form. Please note, that you and a witness must sign the form or we will not be able to process your request.

The request may take up to 30 days to fulfill. Requests for electronic records may take up to 7 days to fulfill. If you are requesting medical and behavioral health records, separate forms must be used.

Completed forms may be submitted in person or by fax to (833) 449-2587 or emailed to:

[email protected]

Informed Consent for Telemedicine and Virtual Communication Services

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