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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.

* Is the resident with medical condition the same as the electric account holder?
* Phone
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
Phone 2
Contact Email Addresses (Up to 2)
Contact Email 1
Contact Email 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.
Information collected on this application is handled in accordance with Hawaiian Electric’s Privacy Policy. The Privacy Policy is available at hawaiianelectric.com/privacy.
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