HMC Physician Directory Simple Change Request Form

Please use this form to submit changes to information that appears in HMC’s online and printed physician directory. Only HMC Medical Staff should use this update form. In order to ensure appropriate presentation and format, all additions/changes that would appear in the online and campus telephone directories are subject to editing and approval by administrators.

If you wish to update any other demographic or CV information, please contact the Medical Staff Department. Download and print HMC Medical Staff Application now.

Hospital Affiliations: *

HMC East

HMC West

Both

First Name: *

Last Name: *

Middle Initials:

Specialty 1:

Specialty 2:

Specialty:

Change Request 1:

Update

Delete

Add

Address (No.1):

Dept./Suite:

Phone:

Fax:

Change Request 2:

Update

Delete

Add

Address (No.2):

Dept./Suite:

Phone:

Fax:

Change Request 3:

Upload a Photo:

Release Agreement: *

I agree

I disagree

I, the undersigned, do hereby grant or deny permission to Hawaii Medical Center (HMC) to use the image of mine. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs and/or images for use in materials that include, but may not be limited to, printed materials such as ID badge, medical staff directory, brochures, newsletters, and digital images such as those on the HMC Web site.

E-Mail Address: To communicate faster and more efficiently with members of the medical staff, please provide your e-mail address below. Please be assured that your e-mail address will be used strictly for internal communications, including messages about changes in clinical policies and procedures, Medical Board information, special events, and important communications from executive leadership. We will not share your e-mail address with any outside source.

E-Mail:

Optional: If you would like your email address to be posted on your physician profile on HMC website, please provide it below

Public E-Mail:

Complete the required authorization information:

Your Name:

Your Phone Number:

Change Authorized By:

This change will not be completed unless the authorization information above is complete. The Medical Staff Office may contact authorizing party for confirmation or clarification.