Form Instructions
HMSA’s 50 Plus Application
To apply for HMSA’s 50 Plus, please print and fill out this form. Mail it
to HMSA at the address below.
To avoid delays, please make sure your application is complete.
- Fill in your name, address and phone numbers.
- Check “yes” if you have other medical or dental coverage and fill in
the name of your carrier. If you are currently enrolled in an employer-sponsored
HMSA plan, please contact the group to cancel your plan. Please note that this plan
does not coordinate benefits with an other medical insurance plan, including Medicare.
Members cannot have any other medical insurance coverage.
- Fill in your present or former HMSA subscriber ID.
- Indicate your desired dental option Participating Provider Program or Dental Network
Program with Hawaii Family Dental Centers. Refer to the Dental Summary to compare
options.
- Fill in your name, sex, birth date, Social Security number, participating health center,
and primary
care provider. The primary care provider must be with the participating
health center specified in the Directory
of HMSA health centers and providers for individual plans. Under "Current
Provider?" check "Yes" if the provider you selected is your current
provider. If the box is not checked and the provider is not accepting new patients or is
a specialist, we will not be able to enroll you with that provider.
- If you are applying for a family plan, please list information for your spouse and
each eligible dependent child.
- Read the agreement, then sign and date the application.
Please include a check or money order payable to “HMSA” for your first two month's
dues. Additional dues may be required if appying after the 10th of the current month.
Mail all application materials to:
HMSA/6-AMS
P.O. Box 860
Honolulu, HI 96808-0860
For more information, call (808) 948-5555 on Oahu or 1 (800) 620-4672
on the Neighbor Islands, Monday through Friday, 8 a.m. - 4 p.m.
Your application is subject to approval by HMSA.
