Form Instructions

2013 HMSA Akamai Advantage Application

Enrollment in Akamai Advantage is possible only at certain times. You may enroll in Akamai Advantage when you first become eligible for Medicare Part A and enroll in Part B. Completed applications must be received by the last business day of a month to be approved for the first day of the next month. For example, applications received by Jan. 31, 2013, will have a proposed effective date of Feb. 1, 2013, subject to CMS approval. You may also enroll during the Annual Election Period, Oct. 15 – Dec. 7, 2012, for a proposed effective date of Jan. 1, 2013, subject to CMS approval or if you qualify for a special election period. Contact our representatives at the phone numbers listed in Contact Information for more information.

To apply for enrollment in Akamai Advantage, print and fill out this form. Mail it to HMSA at the address given on the bottom of this page. You may also fax your completed application to (808) 948-6343 (on Oahu).

All sections of this application must be completed or your enrollment could be delayed.

You’ll need:

• Your Medicare card.
• Your HMSA member number, if you have one.
• Your primary care physician’s name

Section 1

• Write your name, residence address, birth date, sex (gender), mailing address (if different), current HMSA member number (if applicable), daytime telephone number, and email address (optional).
• Write the name of your current primary care provider.
• Propose an effective date, the date you’d like your coverage to start.
• Select the appropriate plan option you wish to enroll in.

Section 2

• Attach a copy of your Medicare card, or your letter from Social Security or Railroad Retirement Board, or fill in the blanks to match your Medicare card.
• Write your name as it appears on your Medicare card, Medicare claim number, sex (gender), and effective date(s) for the coverage(s) you are entitled to under Medicare.

Section 3

• Indicate the premium payment option you want.
• Answer yes or no to the questions and fill in all applicable blanks. Remember, an incomplete application can delay your enrollment.

Section 4

• Read the important information.

Section 5

• Read the agreement and sign and date the form.
• If the applicant is unable to sign, the applicant's legal representative must sign and fill in their name, mailing address and telephone number, and indicate their relationship to the applicant.

Mail application forms to:
HMSA
Akamai Advantage Sales
P.O. Box 3500
Honolulu, HI 96811-3500

Do not send payment with your application. Once your application is approved, we’ll send you a billing statement every month showing you the premium you owe and the date by which we must receive it. Your monthly premium must be paid in advance. If you indicated on the application form that you want your premium withheld from your Social Security Administration (SSA) check or Railroad Retirement Board (RRB) check, we will contact you.

Important: If we do not receive your premiums on a timely basis and reasonable attempts have been made to collect them, your membership in Akamai Advantage will be terminated.

For enrollment information, contact our representatives: Telephone hours are 8 a.m. to 8 p.m., seven days a week.

Oahu: (808) 948-5555
Neighbor Islands: 1 (800) 620-4672 (toll-free)

For the hearing- and speech-impaired:
TTY: 711.