Form Instructions

HMSA’s Individual Dental Plus Plan Application

To apply for HMSA’s Individual Dental Plus 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.

Section A: Subscriber Data

• Fill in your name, mailing address, and phone numbers.
• Fill in your present HMSA medical plan subscriber ID if you have a medical plan with HMSA.
• If you currently have an HMSA individual dental plan and would like that membership canceled if your application is accepted, check "yes" and fill in your dental plan subscriber ID.

Section B: Enrollment Data

• Fill in your name, sex, birth date, and Social Security number.
• If you are applying for a family plan, list information for your spouse and each eligible dependent child.

Section C: Other Insurance

• Check "yes" if you or your dependents have other dental coverage, including HMSA. If yes, fill in the name of the policy holder, name of the other plan, policy holder’s ID number for the other plan, and the other plan’s telephone number.

Section D: Conditions of Enrollment

• Please read the agreement, then sign and date the application. Only the signature of the applicant will be accepted unless you are enrolling a minor child. If signing for a minor, fill in your name and relationship to that child.

Please include a check or money order payable to “HMSA” for your dental membership dues.

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. to 4 p.m.

Your application is subject to approval by HMSA.