Form Instructions

Request for External Review by an Independent Review Organization

From:
Fill in your name, address, telephone number, and HMSA subscriber ID number.

Attach Requested Items:
Read carefully and attach items 1 through 4.

Expedited Review:
If your request qualifies for an expedited review, read carefully and sign.

Experimental or Investigational Attachments:
If a determination that the service under review was experimental or investigational, read carefully and attach items 1 and 2.

Once you’ve filled out the form, please mail it with all attachments to:

Hawaii Insurance Division
Attn: Health Insurance Branch – External Appeals
335 Merchant St., Room 213
Honolulu, HI 96813