Form Instructions

HMSA’s Conversion Plan 10 Application

To apply for HMSA’s Conversion Plan 10, 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.

1. Fill in your name, address and phone numbers.
2. Select either High Option or Basic Option.
3. Check “yes” if you have other medical coverage and fill in the name of your carrier.
4. Fill in your present or former HMSA subscriber ID.
5. Fill in your name, sex, birth date, Social Security number, participating health center, and primary care provider. The primary care provider must be with the participating health center in the Directory of HMSA health centers and providers for individual plans. Under "Current Provider?" check "Yes" if the provider you selected is your 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.
6. If you are applying for a family plan, please list information for your spouse and each eligible dependent child.
7. Read the agreement, then sign and date the application.

Please enclose the following with your application:

• A copy of your HIPAA certificate of coverage.
• A check or money order payable to “HMSA” for the first two month’s dues.

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. - 4 p.m.

Your application is subject to approval by HMSA.