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.
- Fill in your name, mailing address, and home and work telephone numbers.
- Select either High Option or Basic Option.
- Check “yes” if you have ther medical coverage and fill in the name
of your carrier.
- Fill in your present or former HMSA/Health Plan Hawaii number.
- Fill in your name, sex and birth date, and select a participating health center
and personal care physician. The personal care physician must be located at the
participating health center selected.
- If you are applying for a family plan, please list your spouse and dependent children.
Fill in the name, sex, birth date, participating health center, and personal care
physician for each eligible family member. The personal care physician must be located
at the participating health center selected.
- Read the agreement, then sign and date the application.
Please enclose the following with your application:
- A copy of your HIPAA certificate of eligibility (if applicable).
- A check or money order payable to “HMSA” for the first 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
from the Neighbor Islands. Monday through Friday, 8 a.m. - 4 p.m.
Your application is subject to approval by HMSA.