• Bridges to Independent Practice

    Physician Intake Form

  • Confidentiality Statement

    For over thirty years, Pacific Medical Administrative Group ("PMAG") has supported independent physicians in providing high quality, cost-effective healthcare to the people of Hawaii. PMAG is physician driven, physician lead, and is dedicated to supporting its member physicians in developing successful, sustainable practices.

    Respecting the privacy of our physicians is a basic value of Pacific Medical Adminstrative Group. Any personal and/or financial information you share with us is strictly confidential and will not be disclosed or discussed with anyone without your permission and authorization. The information you provide will help us to better understand your needs as an independent physician, and how we can best help your patients and your practice thrive.

    To protect your information, PMAG utilizes a HIPAA-compliant software called Jotform to collect your responses. Read more about how Jotform is keeping your data secure.  

    would like to learn more about PMAG and how to become a member, visit our website at www.pmaghawaii.org. You can also contact us with any questions or concerns at pmag@pmaghawaii.org or call us at (808) 973-6220.

  • Bridges to Independent Practice

    Physician Intake Form

  • PMAG is dedicated to the success of independent physicians in Hawaii. Please fill out the following information to let us know how we can best help you and your practice.  

  • Format: (000) 000-0000.
  • Are you able to receive text messages?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have a physical office location?*

  • PMAG Membership Status

  • Select your PMAG membership status:*

  • Practice Information

  • What patient population do you serve?*
  • Are you a PCP or Specialist?*
  • Will you be enrolling in HMSA’s Payment Transformation Program (PT) with PMAG?*
  • Which Provider Organization are you planning to participate PT with?*

  • What best describes your current situation?

  • I am a:*

  • New Physician Practice

  • Are you buying out/transitioning a retiring physician?*
  • What is their target retirement date?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you interested in a mentorship with a seasoned physician whose practice you could join?*
  • What type of practice are you interested in?*
  • What are you looking to practice as?*
  • Target date of practice opening?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have a specific practice location in mind?*
  • What area(s) are you interested in opening your practice?
  • Do you have the ability to finance the start up costs of your practice?
  • Are you considering loan financing options?
  • Do you have a Hawaii Medical License?*
  • Are you credentialed with any insurance companies?*
  • What insurance(s) are you credentialed with?

  • Physician Transition to Part-time or Retirement

  • Are you:*
  • What is your target date to transition to part-time?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Why are you reducing your practice hours?
  • What is your target retirement date?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have a practice transition plan?*
  • What is your practice transition plan?*
  • Are you willing to mentor this physician after the transition?
  • Select the practice transition plans you are interested in:*
  • What area(s) do you most need help with?
  • Should be Empty: