Form Instructions

HMSA’s Student Plan 19 Application

To apply for HMSA’s Student Plan 19, 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, sex, mailing address, and birth date.
Check “yes” if you have ther medical coverage and fill in the name of your ther carrier.
Fill in your present or former HMSA/Health Plan Hawaii number.
Read the agreement, then sign and date the application.
Fill in the name and address of your educational institution.

Please enclose the following with your application:

Proof of your current school registration showing full-time status.
Completed group term life and accidental death and dismemberment contract and beneficiary designation form.
A check or money order payable to “HMSA” for your first quarter’s plan dues.

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.