Form Instructions

Authorization to Request, Use or Release Member Psychotherapy Notes Form

With this form, you agree to release your or your dependent’s psychotherapy notes to another adult or organization.

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.

Part A. Member authorizing request and/or release

Print your name (or the name of the person whose psychotherapy notes are being requested, used or released), HMSA number, birth date, and contact number.

Part C. Authorization request

Let us know the purpose of the release, how long you will allow access, and the recipient’s name(s).
To authorize more than two people or organizations, please complete and attach another form.
Print your name and sign and date the form.

Mail completed forms to:
HMSA
Membership Service
P.O. Box 860
Honolulu, HI 96808-0860