Medical Needs Communications Form

Please complete all required fields and click SUBMIT to ensure your form is received. If you previously provided us with contact information and would like to update it, please visit our emergency outage communications information update page.

Contact Information

* Resident With Medical Condition First Name:

* Resident With Medical Condition Last Name:

Account Number:

* Is the resident with medical condition the same as the electric account holder? Yes No

If No, please provide the name of the electric account holder:

* Service Address:

* Service City:

* Service State:

* Service Zip Code:

Mailing Address
(If different than service address):

Mailing City:

Mailing State:

Mailing Zip Code:

* Phone

Type

Phone Number:

* Email Address:
We will send confirmation of your application submission to this email. This email will be used if you want to update your PSPS or extended outage notification preferences in the future.

* Confirm Email Address:

Contact preferences for PSPS and other planned outages

Please make sure Hawaiian Electric has your correct contact preferences so we can reach you in advance of a planned public safety power shutoff (PSPS) or other situations that may result in an outage. In certain situations, we may also send a letter. All contact preferences will be used during a PSPS event. Up to two contacts can be submitted for each contact method below.

* Contact Method (Please enter at least 1 Contact Method)

Contact Phone Numbers (Up to 2)

Phone 1

Type

Contact Phone Number 1:

Phone 2

Type

Contact Phone Number 2:

Contact Email Addresses (Up to 2)

Contact Email 1

Contact Email Address 1:

Confirm Contact Email Address 1:

Contact Email 2

Contact Email Address 2:

Confirm Contact Email Address 2:

* I consent to Hawaiian Electric sharing my name, address, and telephone number with emergency response agencies, and/or nonprofit agencies assisting in emergency response, for the purpose of checking on my well-being and/or assisting me during a PSPS or other extended outage. Yes No

* I certify the above information is correct. I also certify the Special Medical Needs resident lives full-time at this address and requires PSPS notifications. I agree to allow Hawaiian Electric to verify this information. I also agree to notify Hawaiian Electric promptly if the qualified resident moves or the resident no longer needs the Special Medical Needs Communications.

* I agree to the following Terms & Conditions:

I have a medical condition that requires the use of electricity at home.
Hawaiian Electric cannot guarantee uninterrupted electrical service. I am responsible for making alternate arrangements in the event of an electric outage.

Information collected on this application is handled in accordance with Hawaiian Electric’s Privacy Policy. The Privacy Policy is available at hawaiianelectric.com/privacy.

* Electronic signature (full name):

Date:

DISCLAIMER: By typing your full name, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

* Required

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Medical Needs Communications Form