Form Instructions

Health History for Subscriber and Dependent(s)

Each person applying for membership in an HMSA individual plan, including dependent 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