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Form Instructions

HMSA’s PPO Conversion Plan Application

To apply for HMSA’s PPO 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, mailing address, birth date, sex, and home and work telephone numbers.
2. Check “yes” if you have ther medical or dental coverage and fill in the name of your carrier.
3. If you are currently enrolled in an HMSA individual medical plan, your coverage will be canceled upon enrollment in this plan. Please check “yes” to confirm that you understand this.
4. Fill in your present or former HMSA/Health Plan Hawaii number.
5. If you are applying for a family plan, list the name, sex and birth date for your spouse and each eligible dependent child.
6. 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-AMS
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.