Help Request Form

The information you choose to share below will help us understand your needs better and enable our team to offer options that can best meet your needs and values.  

Hawai‘i Care Choices is committed to maintaining confidentiality, and security of personal information under HIPAA regulations.  However, please note that this form is not protected, as it serves only as a guide to help us determine whether our services may be of benefit to you or your loved one.