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 home and work telephone numbers.
- Check “yes” if you have ther 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.
- Fill in your present or former HMSA/Health Plan Hawaii number.
- Indicate your desired dental option. Refer to the Dental Summary to compare options.
- List the name, sex, birth date, participating health center, and personal care physician
for yourself, your spouse, and each eligible dependent child. The personal care
physician must be with the participating health center selected.
- Read the agreement, then sign and date the application.
Please include a check or money order to cover your monthly
dues from your date of cancellation from an HMSA group plan up to the current
month. Your check or money order should be payable to “HMSA.”
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
from the Neighbor Islands. Monday through Friday, 8 a.m. - 4 p.m.
Your application is subject to approval by HMSA.