Form Instructions
HMSA’s Individual Care Plan Application
To apply for HMSA’s Individual Care 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, home and work telephone numbers, and mailing address.
- Select either High Option or Basic Option.
- Check “yes” if you have ther medical coverage and fill in the name
of your carrier.
- If you are currently enrolled in an HMSA/Health Plan Hawaii individual plan (Conversion
Plan, Conversion Plan 10, Plan 6, Student Plan 19, or HPH Individual Conversion
Plan) and would like your current coverage canceled if you are accepted in this
plan, check “yes.” You may be required to complete a plan waiver form
at the time of acceptance.
- Fill in your present or former HMSA/Health Plan Hawaii number.
- Fill in your name, sex, birth date, participating health center, and personal care
physician. If you are applying for a family plan, complete this information for
your spouse and each eligible dependent child. The personal care physician must
be located at the participating health center selected.
- Read the agreement, then sign and date the application.
Please enclose the following with your application:
- Individual plan authorization for medical records.
- Health history for yourself and all dependents.
Please do not send any money at this time. Upon approval of your application, HMSA
will send you a bill.
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.