Form Instructions

Prenatal Care Member Enrollment Form

To become a member of this program at no cost, please print and fill out this form. Submit it to HMSA’s Prenatal Care Services.

To avoid delays, please make sure your application is complete.

• Fill in your name, birth date, address, telephone numbers, email address, and HMSA number.
• Tell us when we may call you to arrange an appointment and which number you’d like us to call.
• Provide your OB care provider’s name, location, and telephone number.
• Indicate your due date and if you’re currently receiving prenatal care.
• Sign and date the form.
• Submit this form with your Permission to Share Medical Information form.

Fax or mail all materials to:
HMSA’s Prenatal Care Services
1600 Kapiolani Blvd., Suite 920
Honolulu, HI 96814

Fax: 1 (800) 952-4460