Durable Medical Equipment (Dme) Supplier License Application Instructions
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1
2DAVID Y. IGE
VIRGINIA PRESSLER, M.D.
GOVERNOR OF HAWAII
DIRECTOR OF HEALTH
In reply, please refer to
file:
STATE OF HAWAII
DEPARTMENT OF HEALTH
OFFICE OF HEALTH CARE ASSURANCE
601 KAMOKILA BOULEVARD, ROOM 337
KAPOLEI, HAWAII 96707
DURABLE MEDICAL EQUIPMENT (DME) SUPPLIER
LICENSE APPLICATION INSTRUCTIONS
Please read carefully to ensure accuracy in completing the application.
GENERAL INSTRUCTIONS:
•
Complete in full; incomplete applications will not be considered for licensure.
•
Type or print clearly; illegible applications will not be considered for licensure.
Sign documents that have a signature line.
•
Only use the application form provided. OHCA will not accept altered application forms.
•
Attach documents and provide explanations on additional pages, if needed.
•
APPLICATION FORM INSTRUCTIONS:
1.
Name of Applicant: This is the company name and Trade Name (if applicable), as
registered in the State of Hawaii or as registered in the company's home state.
Check the box that best describes your type of business.
2.
Hawaii State Tax Identification Number (GE number): Enter the Hawaii State Tax ID
number. A valid Hawaii State General Excise Tax Identification Number is required
†
for Hawaii State Durable Medical Equipment Supplier licensure.
†
For out-of-state applicants, if your business has no nexus and no employees in the
State of Hawaii, you are exempt from obtaining a Hawaii General Excise Tax License.
Please submit a formal letter stating you have no nexus and no employees in Hawaii
along with your DME Supplier License application.
3.
Name of Responsible Contact, Location Address, Mailing Address, Business Phone
Number, E-Mail Address: This is the name of the person or agent who will be
responsible for providing timely and satisfactory services to consumers during working
hours, and the person's or agent's contact information.
4.
Include $350.00 License Fee Payment: Verify payment as cashier’s check or money
order payable to “Director of Finance.” Please input “DME License Fee” in the memo
section. DO NOT SEND CASH OR PERSONAL CHECK. Payments by credit card
cannot be accepted at this time. This fee will be refunded for applications that are
deemed unacceptable or not approved. If applicable, please provide the State of Hawaii
Board of Pharmacy license number and license expiration date, then check the “Exempt”
box. Applicants whose State of Hawaii Board of Pharmacy license numbers begin with
the “PHY-“ or "PMP-" prefix will be considered for exemption.
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