Form Instructions

Prenatal Care Permission to Share Medical Information

We may need your medical information to identify atypical conditions, coordinate special treatment, or arrange for case management. 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, address, telephone number, and HMSA number.
• Fill in the names and telephone numbers of two providers.
• Check off the categories of protected health information you will allow.
• Initial next to the amount (all or specific portions of) information accessible for your care.
• Sign and date the form. Include the signature of your authorized representative, if you are under the age of 18.
• Submit this form with your application.

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

Fax: 1 (800) 952-4460