​Dear Medical Professional:This form will be used to determine the members most appropriate mode of transportation based on his or her functional abilities and limitations. 

​Note: (Ohana Health Plan and AlohaCare) If member is eligible for Handivan services or can ride The Bus (HONOLULU, HI ONLY) This form is not needed, please call our facility line at 808-237-2952 .

Member Address

Medical Info

Home Life

Physical Abilities and Equipment

Does Member use any of the following assistive devices?

Cognitive Abilities:Does the patient have problems with any of the following? If yes, choose a rating for each category, with 1 being mild impairment and 5 being severe impairment.

Sensory Abilities

Medical Professional Info

*By signing, the medical professional certifies and attests that each statement is accurate and true to the best of their knowledge.