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Account Holder Details
Create Account
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This account will help you apply for and manage your health coverage over time. We are
committed to protecting your personal information.
Required fields are marked with an asterisk(*).
FIRST NAME*
LAST NAME*
EMAIL*
RE-ENTER EMAIL*
USER NAME*
PASSWORD*
Password Policy
Password must not match or contain first name.
Password must not match or contain Last Name.
Password must contain at least 2 alphabetic character(s).
Password must be at least 6 character(s) long.
Password must contain at least 1 lower case letter(s).
Password must contain at least 1 numeric character(s).
Password must contain at least 1 upper case letter(s).
Password must start with an alphabetic character.
Password must not match or contain user name.
RE-ENTER PASSWORD*
SECURITY QUESTION*
YOUR ANSWER*
SECURITY QUESTION*
YOUR ANSWER*
SECURITY QUESTION*
YOUR ANSWER*
Are you registering as a DHS Application Counselor?*
A DHS Application Counselor is someone who is authorized by the State of Hawaii to assist
others to apply for benefits. DHS Application Counselors must be approved by the State of
Hawaii before an application can be entered.
This field is required
Yes
No
reCAPTCHA field is required
If you are looking to buy health insurance without assistance, please visit the Federal Health Insurance Marketplace site at
www.healthcare.gov
