Form Instructions

HMSA Akamai Advantage Enrollment Change Form

This form is for current Akamai Advantage members who want to switch to another Akamai Advantage option. You must print and fill out this change form. Mail your completed form to HMSA at the address on the bottom of this page. You may also fax your completed application to (808) 948-6343 (on Oahu).

Enrollment changes are possible only at certain times during the year. In general, enrollment or changes are allowed only during the Annual Election Period, Oct. 15 – Dec. 7, 2012, for an effective date of Jan. 1, 2013, unless you qualify for a special election period. If you miss the Annual Election Periods, you must wait until Oct. 15 - Dec. 7, 2013, for an effective date of Jan. 1, 2014. Enrollments are subject to approval from the Centers for Medicare and Medicaid Services. Contact our representatives at the phone numbers listed in Contact Information for more information.

Note: If you have coverage through a group-sponsored arrangement, please contact your benefits administrator before making any changes.

All three sections of this change form must be completed or your enrollment change could be delayed.

Section 1

• Write your name, residence address, birth date, sex (gender), mailing address (if different), current HMSA member number, daytime telephone number, and email address (optional).
• Write the name of your primary care provider.
• Check your current Akamai Advantage option and what Akamai Advantage option you would like to change to.
• Fill in the month you would like your Akamai Advantage option to start.
• Check the box to request information in large-print format.

Section 2

• Please read this important information.
• Indicate the payment option you want.

Section 3

• Read 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 change forms to:
HMSA
Akamai Advantage Sales
P.O. Box 3500
Honolulu, HI 96811-3500

Do not send payment with your change form. Once your enrollment change is approved, we’ll send you a billing statement every month showing you the premium you owe and the due date. You must pay your monthly premium in advance. If you indicated on the change form that you want your premium withheld from your Social Security Administration (SSA) 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.