Health History for Subscriber and Dependent(s)
Each person applying for membership in an HMSA individual plan, including
family members, must complete and attach a health history to their application.
Please print and fill out this form. Mail it to HMSA at the address below.
To avoid delays, please make sure your information is complete.
- List the name, height and weight of each family member applying for coverage.
- Fill in the subscriber’s telephone numbers.
- If you’ve previously applied for an HMSA plan, check “yes” and give details.
- Check off answers to yes/no questions and provide explanations for each.
- List prescription medications taken by each applicant.
- Have each applicant 18 years or older sign and date the forms.
- Attach this to your application and Individual Plan Authorization for Medical Records form.
Mail all application materials to:
HMSA / 6-AMS
P.O. Box 860
Honolulu, HI 96808-0860