Form Instructions
HMSA’s Dental Network Plan Enrollment Form
To apply for HMSA’s Dental Network Plan, 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.
Section A: Subscriber Data
- Fill in your name, mailing address, and home and work telephone numbers.
- Fill in your present HMSA medical plan number.
- Circle “yes” if you have an HMSA individual (non-group) dental HMO plan
now and wish to cancel that membership if this application is accepted.
Section B: Select Your Coverage
- Select a dental center to receive all of your services.
Section C: Enrollment Data
- Fill in your name, sex and birth date. If you select the Dental Independent Network,
you must also select a primary care dentist for yourself.
- If you are applying for a family plan, please fill in the name, sex and birth date
of each eligible family member. If you select the Dental Independent Network for
them, you must also select a primary care dentist for each eligible family member.
Section D: ther Insurance
- Check "yes" if you or your dependents have ther dental coverage, including HMSA.
If yes, fill in the name of the policy holder, name of the ther plan, policy holder’s
ID number for the ther plan, and the ther plan’s telephone number.
Section E: Conditions of Enrollment
- Please read the agreement, then sign and date the application.
Please include a check or money order payable to “HMSA” for the annual
membership dues.
Mail all application materials to:
HMSA/6-CSS
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.