Form Instructions
The HMSA Children’s Plan Enrollment Form
To apply for The HMSA Children’s 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.
Please complete a separate form for each child you want to enroll.
- Fill in your name, home and work telephone numbers, and mailing address.
- Check “yes” if your child has ther medical coverage and fill in the name of the
carrier.
- Fill in your child’s present or former HMSA/Health Plan Hawaii number.
- Fill in the child’s name, sex and birth date, and choose a health center and personal
care physician for your child. The personal care physician must be located at the
participating health center selected.
- Read the agreement, then sign and date the application on behalf of your minor child.
Please include a check or money order payable to “HMSA” for your child’s
first month’s dues. If you are enrolling more than one child in this plan,
you may submit one check or money order for the combined dues for the first month
of coverage.
Mail all application materials to:
HMSA/6-CSS
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.