Health Plan Forms

Plan Enrollment Forms

• 50 Plus
• 2012 65C Plus Change Form
• 2013 65C Plus Change Form
• 2012 Akamai Advantage
• 2013 Akamai Advantage
• 2012 Akamai Advantage Change Form
• 2013 Akamai Advantage Change Form
• Catastrophic Care Plan
• The HMSA Children’s Plan
• Conversion Plan 10
• HPH Conversion Plan
• Individual Dental Plan
• Individual Care Plan
• PPO Conversion Plan
• Student Plan 19

Medicare Plan Forms

• Appointment of Representative
• Coverage Determination Request
• Organization Determination Request
• Member Appeals

Claim Filing Forms

• Dental Claim Form

Additional Forms

• Acknowledgement of Group Life and ADD Coverage under Plan 19
• Coordination of Benefits (COB) Subscriber Questionnaire Form
• Dues Payment Authorization Form (Medicare Plans)
• Automatic Payments Form (Individual Plans)
• Health History for Subscriber and Dependent(s)
• HMSA’s Care Access Assistance Program (CAAP) Request Form
• HSTA Travel Reimbursement Benefit Request Form
• HMSA’s Third-Party Liability Injury/Illness Report Form
• Individual Plan Authorization for Medical Records
• Workers’ Compensation Questionnaire Form