The 29 Hawaii forms that ask for a clinician's input, from workers' comp treatment plans and school health records to TB clearance, POLST and aid-in-dying reports.
This page lists the 29 Hawaii forms that ask for a clinician's input, grouped by program. On workers' comp claims the attending physician files the WC-2 Physician's Report through the DCD portal and sends the Hawaii Workers' Compensation Treatment Plan to the employer or carrier for approval. Students need the DOE Form 14 Student's Health Record and a TB clearance on the State of Hawaii TB Clearance Form (TB Document F). The PA-3 covers disability parking placards and special plates statewide.
The WC-2 initial report is due within 7 days of first service, and the treatment plan is required under HAR 12-15-32 when treatment goes beyond the initial visits. Temporary disability claims use the TDI-45, which the employee gets from the employer because it isn't published online. The Hawaii POLST needs a wet signature. Under the Our Care, Our Choice Act, every patient also needs a counseling provider's determination. Vero Documents fills PDF forms from the visit note and the chart, and you review and sign.
Attending physician's standardized treatment plan (diagnosis, modalities, frequency, measurable goals, cost estimate) that the employer/carrier approves or denies before treatment proceeds.
Attending physician's initial and interim report to the employer/carrier and DCD on the injury, diagnosis, treatment and work status.
Patient-prescriber informed consent required before long-term opioid prescribing, which DCD lists among workers' compensation forms.
Employee's claim for Hawaii Temporary Disability Insurance benefits for a non-work-related illness or injury, with the attending practitioner's certification of disability.
DOT-H2058Medical examination report giving the county examiner of drivers information on whether the applicant meets Hawaii's physical and mental licensing standards; may be referred to the Medical Advisory Board (NHTSA Driver Fitness Medical Guidelines).
Applies for a temporary (red), long-term (blue) or Disability Paid Parking Exemption (green) placard or special license plates, with a medical certification of the qualifying impairment.
Form 14Required health record for entry to a Hawaii school or preschool: physical examination within one year before entry and before 7th grade, plus immunizations.
Certifies TB clearance (risk assessment, symptom screen, TST/IGRA or CXR) required for school, child care and other settings in Hawaii.
Supplement to DOE Form 14 recording developmental, vision, hearing and other screenings and special care needs for children in licensed child care/preschool.
DHS 984Medical report and TB clearance for child care applicants, employees and household members in licensed child care facilities.
TB Document FDepartment-approved certificate of tuberculosis clearance required under HAR 11-164.2 for school entry, school/child care employment, food handlers in certain settings, and other covered groups.
Department-approved TB risk assessment used to decide whether testing is needed before issuing a Hawaii TB clearance.
TB Document HDepartment-approved screen for signs and symptoms of TB disease used in the TB clearance process.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
WIC Form FD 141CMedical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Portable medical order recording CPR, treatment intensity and nutrition decisions for seriously ill patients in Hawaii.
Reports the outcome and circumstances of death of a patient who received aid-in-dying medication.
Documents the attending provider's compliance with the Our Care, Our Choice Act when prescribing medical aid-in-dying medication.
Consulting provider confirms diagnosis, prognosis and capacity of a patient requesting medication under the Our Care, Our Choice Act.
Mandatory mental health counseling determination that the patient is capable and not suffering from undertreated depression or another condition impairing judgment.
Certifying physician or APRN certifies the patient's debilitating condition (or primary-treating-provider/hospice certification) on the patient's 329 registry application and sends it to DOH for approval.
Written notice to void a patient's 329 registration card because the patient died, no longer has a debilitating condition, or benefits no longer outweigh risks.
Written report by a mandated reporter of suspected child abuse or neglect, completed before the oral report and sent after it to satisfy HRS 350-1.1's written-report requirement.
DOH/EPI 11/97Reports a notifiable communicable disease (HAR Title 11, Chapter 156) other than tuberculosis, Hansen's disease, STDs or AIDS to the county DOH office.
DHS 1640 WEBOnline report of suspected abuse, neglect or financial exploitation of a vulnerable adult to Adult Protective Services.
Physician, optometrist or audiologist certifies blindness, deafness or total and permanent disability so the taxpayer can claim Hawaii's special income-tax and general-excise-tax exemptions.
Physician certification that a hunter meets a permanent disability criterion (mobility aid, blindness, limb loss, lung disease, AHA class III/IV cardiac) to hunt and shoot from a vehicle on public hunting areas.
Physician certification that a hunter's physical disability makes regular archery equipment unusable, allowing crossbow use on public hunting areas.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Through DCD portal access only. There is no downloadable form, and the old 9/05 paper version is no longer accepted. The attending physician files the initial report within 7 days of first service, then interim and final reports, with copies to the employer or carrier (HRS 386-96, HAR 12-15-80). When treatment goes beyond the initial visits, send the Hawaii Workers' Compensation Treatment Plan to the employer or carrier, who approves or denies it.
The patient's own licensed practitioner: a physician, APRN or PA. The DOH TB Branch does not complete it. The provider does a risk assessment on TB Document G, a symptom screen on TB Document H and testing as needed, then signs or stamps the State of Hawaii TB Clearance Form. Under HAR 11-157, all students new to Hawaii schools need TB clearance, and the form is also used for school and child care employment.
A Hawaii-licensed physician, naturopathic physician, podiatrist, APRN or physician assistant completes side 2, the medical certification. A U.S. Armed Services medical license held by a provider stationed in Hawaii is also accepted, and DCAB takes an original or electronic signature. The form covers temporary (red) placards valid up to 6 months, long-term (blue) placards, the green Disability Paid Parking Exemption placard and special plates. The applicant submits it to the county.
No. The Hawaii POLST needs a wet signature from a Hawaii-licensed physician, APRN or PA who has examined the patient. Kokua Mau prints it on lime-green paper, but white copies are legal, and the pre-2023 version remains valid. The form records CPR, treatment intensity and nutrition decisions under HRS 327K, and it stays with the patient.