Form Instructions
Member Authorization Form
This form allows you to authorize a person or organization to act on your behalf
with regard to your HMSA plan or to receive your medical information that you specify.
Read the items on the top of the form.
Please print and fill out this form. Mail it to HMSA at the address on the bottom
of the form.
IMPORTANT: Please make sure your application is complete.
Incomplete forms will
not be processed.
Part A: Member Information
Print the following REQUIRED information: Your name, HMSA member ID number, birth
date, telephone number, address, city, state, and ZIP code.
Part B: Inclusion of Minor Children
If you would like your authorization to be applicable to your minor children (i.e.,
under 18 years of age) as well as yourself, please print their full names here.
Note: If the authorization is ONLY for your minor child and not for yourself, please
use Part A to list your minor child’s information. (You may list additional minor
children in Part B.)
Part C: Scope of Authorization, Purpose and Expiration
- Check the appropriate boxes in the Options, Purpose and Expiration columns. (Check
one box per column.)
- If you checked the Restricted box in the Option column, check the appropriate boxes
in the Description column.
Part D: Third Party Information
Fill in the name of the person or organization you are authorizing and their address,
telephone number, and relationship to you (if applicable).
Print your name in the following section, and sign and date the form. A parent making
an authorization concerning a minor child (see instructions for Part A above) should
print and sign the parent’s name here.
Mail completed form to:
HMSA
Membership Service
P.O. Box 3500
Honolulu, HI 96811-3500