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Form Instructions

HMSA’s HPH Conversion Plan

To apply for HMSA’s HPH Conversion 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.

1. Fill in your name, home and work telephone numbers, mailing address, and ther medical coverage information.
2. Fill in your present or former Health Plan Hawaii number.
3. Fill in your name, sex, birth date, participating health center, and personal care physician in the subscriber section. The personal care physician must be located at the participating health center specified.
4. If you are applying for a family plan, fill in the name, sex, birth date, participating health center, and personal care physician for your spouse and each eligible dependent child. The personal care physician must be located at the participating health center selected.
5. Read the agreement, then sign and date the application.

Please include a check or money order payable to “HMSA” for your first month’s 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.