Form Instructions

Individual Plan Authorization for Medical Records

HMSA must review applicants’ protected health information to determine their eligibility for certain benefits. 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.

Note: You have the right to decline, but without this information, we may be unable to reasonably determine eligibility. Consequently, we may decline your enrollment in the health plan.

• Fill in your name, name(s) of dependents, address, telephone number, and email address.
• Read sections B and C.
• Sign and date the form. Signatures are required for all adult dependents applying for coverage.
• Attach this to your application.

Mail all application materials to:
HMSA/6-AMS
P.O. Box 860
Honolulu, HI 96808-0860