Request to Amend Member Information Form
This form is used to request that HMSA amend information about you that is in our
possession. This form may only be signed by the member or a person with the legal
authority to sign for the member.
Please print and complete the form in its entirety. Incomplete forms will not
be processed and will be returned.
Part A - Member Information:
Complete all information in this section for the member whose records are to be
amended. All fields are required.
- Last Name – Enter legal last name as it appears on the HMSA membership card.
- First Name – Enter legal first name as it appears on the HMSA membership card.
- MI – Enter middle initial(s).
- Address – Enter street address (e.g., "123 Any Street").
- City – Enter name of the city (e.g., "Honolulu").
- State – Enter state abbreviation (e.g., "HI").
- ZIP Code – Enter five-digit ZIP code. If known, include ZIP +4.
- Email – Enter an email address, if available.
- Home Phone – Enter a home telephone number with area code.
- Cell Phone – Enter a cell phone number with area code.
- HMSA Subscriber Number(s) – Please include the HMSA subscriber number(s) as indicated
on the HMSA membership card. If more than one member ID exists, include all HMSA
IDs that this authorization should apply to.
- Birth Date – Enter the birth date in the format mm/dd/yyyy (e.g., 07/15/1990).
Part B - Information Requested to be Amended:
Select the appropriate categories of information you wish to be amended from the
choices provided. Include a description of the amendment you wish to make and state
a reason for the amendment request. Please be as specific as possible. If you are
enclosing supporting documentation, briefly describe the supporting documentation.
Part C - Person or Organization to be Notified of the Amendment:
If you would like us to notify a person or organization of the amendment, please
complete the following:
- Last Name – Enter last name of the person to be notified.
- First Name – Enter first name of the person to be notified.
- MI – Enter middle initial of person to be notified.
- Address – Enter street address (e.g., "123 Any Street") of the person
to be notified.
- City – Enter name of the city (e.g., "Honolulu") of the person to
- State – Enter state abbreviation (e.g., "HI") of the person to be
- ZIP Code – Enter five-digit ZIP code of person to be notified. If known, include
- Organization Name – If notification is to be sent to an organization, state the
name of the organization. Organization notifications should include the name and
contact information of an individual within the organization.
- Phone Number – Enter a telephone number of the person to be notified with area code.
- Fax Number – Enter a fax number with area code, if applicable, of the person to be notified.
Part E - Your Individual Rights:
This section of the form describes your rights as indicated by applicable state
and/or federal laws.
Part F - Signature:
The member should print their name and sign at the bottom of the form. If a person
with legal authority other than the member is signing the form, please print the
name of the person with legal authority and the relationship of the person to the
member, and provide a copy of documentation verifying the legal authority (e.g.,
a copy of a legal power of attorney).
Return the completed form to the following address:
HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860