Form Instructions
The HMSA Children’s Plan Application
To apply for The HMSA Children’s Plan, please print and fill out this form.
Mail it to HMSA at the address below.
To apply:
A completed application and payment must be received by the 12th of the month for
a proposed effective date of 1st of the following month.
If re-enrolling in The HMSA Children's Plan in the same year, you must apply within
31 days from a qualifying event or be subject to November's open enrollment for
January 1 effective date.
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, address, and phone numbers.
- Check “yes” if your child has other medical coverage and fill in the name of the carrier. Please note that
this plan does not coordinate benefits with any other medical insurance plan. Once
accepted into this plan, members cannot have any other medical insurance coverage.
- Fill in your child’s present or former HMSA subscriber ID.
- Fill in the child’s name, sex, birth date, and Social Security number. Then
choose a health
center and primary care provider that’s participating with the
HMSA Children’s Plan. Under "Current Provider?" check "Yes"
if the provider you selected is your child’s current provider. If the box
is not checked and the provider is not accepting new patients or is a specialist, we will not be able to enroll you with that
provider.
- 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 payment for the combined dues for the first month of coverage.
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
on the Neighbor Islands, Monday through Friday, 8 a.m. to 4 p.m.
Your application is subject to approval by HMSA.
