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Health Plans

Plan Enrollment Forms

• HMSA’s 50 Plus Application
• HMSA’s 65C Plus Change Form
• HMSA’s 65C Plus Enrollment Application
• HMSA’s Catastrophic Care Plan Application
• The HMSA Children’s Plan Enrollment Form
• HMSA’s Conversion Plan 10 Application
• HMSA’s Dental Network Plan Enrollment Form
• HMSA’s HPH Conversion Plan
• HMSA’s Individual Care Plan Application
• HMSA’s PPO Conversion Plan Application
• HMSA’s Student Plan 19 Application

Additional Forms

• Appointment of Representative
• Acknowledgement of Group Life and ADD Coverage under Plan 19
• Coordination of Benefits (COB) Subscriber Questionnaire Form
• Dues Payment Authorization Form
• Health History for Subscriber and Dependent(s)
• HMSA’s Care Access Assistance Program (CAAP) Request Form
• HMSA’s Mail Order Prescription Drug Program
• HMSA Coverage Determination Request
• HMSA Organization Determination Request
• HMSA’s Third-Party Liability Injury/Illness Report Form
• Individual Plan Authorization for Medical Records
• Member Appeals
• Workers’ Compensation Questionnaire Form