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.
- Fill in your name, telephone numbers, mailing address, and other medical coverage
information.
- Fill in your present or former HMSA membership number.
- Fill in your name, sex, birth date, Social Security number, participating health center,
and primary care provider (PCP) in the subscriber section. The PCP must
be with the participating health center specified in the
Directory of Health Centers and Providers for the individual plans. Under
"Current Provider?" check "Yes" if the provider you selected
is your current provider.
- If you are applying for a family plan, please fill in the name, sex, birth date,
Social Security number, participating health center, and PCP for your spouse and
each eligible dependent child. The PCP must
be with the participating health center specified in the
Directory of Health Centers and Providers for the individual plans. Under
"Current Provider?" check "Yes" if the provider you selected
is your current provider.
- Read the agreement, then sign and date the application.
Please include a check or money order to cover your monthly dues from your date of cancellation from an HMSA group plan up to the current
month. Your check or money order should be payable to "HMSA."
Mail all application materials to:
HMSA/6-AMS
P.O. Box 860
Honolulu, HI 96808-0860
For more information, call (808) 948-5555 on Oahu or 1 (800) 620-4672
on the Neighbor Islands, Monday through Friday, 8 a.m. - 4 p.m.
Your application is subject to approval by HMSA.
