Become a Vendor

Please click here to access the Interested Vendor Form. Once completed, DVR will vet your organization’s submission. To properly complete the form:

• You will need all information about your ability to provide services.
• The form should be completed once per Vendor organization.
• There is not an option to save progress while filling out the form.

Click here to access the Master Services Agreement (MSA) and Service Specifications for all services

The link above will guide you through the necessary information needed in the MSA. Once the required fields are completed and submitted, the MSA will be sent directly to Knowledge Services.

• Please Note: No redline requests will be accepted for this agreement. All MSAs must be submitted electronically through the link above. The MSA document will time out after an extended period of time. Once all content is reviewed, please refresh the document before completing.

At the time of MSA submission, you must attach the following:

• Compliant Certificate of Insurance (COI)
• Signed W-9 Form
• Tax clearance certificate from the Director of Taxation, State of Hawaii, and the Internal Revenue Service, U.S. Department of the Treasury
• Certificate of compliance issued by the Department of Labor and Industrial Relations, State of Hawaii, in accordance with section103D-310, HRS, and section 3-122- 112, HAR, that is current within six (6) months of the date of issuance.
• Certificate of good standing issued by the Department of Commerce and Consumer Affairs, State of Hawaii, in accordance with section 103D-310, HRS, and section 3-122-112, HAR, that is current within six (6) months of the date of issuance.

*In lieu of the above certificates from the Department of Taxation, Labor and Industrial Relations, and Commerce and Consumer Affairs, Vendors may submit proof of compliance through Hawaii Compliance Express (HCE) or through the State Procurement Office’s designated certification process and shall provide written proof of compliance.

Click here to download a blank W-9 Form.

Please reference this sample Certificate of Insurance to view the standard insurance requirements for the State of Hawaii.

On the COI, complete the Certificate Holder area as follows:

Knowledge Services and the State of Hawaii
9800 Crosspoint Boulevard
Indianapolis, IN 46256

Please email the HIVRS team with any questions.

Click here to access the Vendor Enrollment Form

In order to complete the enrollment process under the HIVRS MSP Program, please complete one Vendor Enrollment Form on behalf of your company.

• Please note: This form includes the relevant information requested on the Med-Quest Provider Enrollment Form.

Click here to access the VRS Vendor Profile Form

In order to provide new VR Participants with the capabilities and contact information for your organization, we must have a completed VRS Vendor Profile Form. Additionally, on this form, please indicate which email address should be utilized for Purchase Orders and Clearance Emails to be sent.

Your organization can submit a new VRS Vendor Profile Form at any time to replace the information the MSP has on file for your organization.

Click here for the Vendor Personnel Compliance Form

This form includes the FieldPrint Fingerprint-Based Background Check with Fingerprint Clearance Card, Tuberculosis Test Confirmation, HireRight Confirmation, Affirmation of Qualifications, and if applicable, licensure validation.

This form must be completed for each individual (supervisors and vendor representatives) providing direct participant services in your organization.

Click here to access the Exhibit C – Vendor Code of Conduct

By signing this document, you are agreeing to DVR’s Code of Conduct on behalf of your Vendor Company.

Click here to access the Vendor ACH/EFT Disbursement Set-Up Form

In order to receive ACH payments through the HIVRS MSP Program, please complete one (1) Vendor ACH/EFT Disbursement Set-Up Form on behalf of your company.

Please attach the following applicable forms of documentation to complete the registration process:

• For Checking Accounts: Voided check imprinted with company name and  Copy of Bank Identification from bank (must show Ban Routing/ABA # and Account Number)
• For Savings Accounts: Voided deposit slip and  Copy of Bank Identification from bank (must show Ban Routing/ABA # and Account Number)