HMSA’s Catastrophic Care Plan Application
To apply for HMSA’s Catastrophic Care Plan, 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 coverage and fill in the name of
- If you are currently enrolled in an HMSA individual medical plan, your coverage
will be canceled upon enrollment in this plan. Please check "yes" to confirm that
you understand this.
If you are currently enrolled in an employer-sponsored HMSA plan, please contact
the group to cancel upon your acceptance into this plan.
Please note: This plan does not coordinate benefits with any other medical insurance
plan, including Medicare. Once accepted into this plan, members cannot have any
other medical insurance coverage.
- Fill in your present or former HMSA subscriber ID.
- Fill in your name, sex, birth date, and Social Security number.
- If you are applying for a family plan, list information for your
spouse and each eligible dependent child.
- Read the agreement, then sign and date the application.
Please enclose the following with your application:
Please do not send any money at this time. Upon approval of your application, HMSA
will send you a bill.
Mail all application materials to:
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.