Authorization to Request or Release Member Information Form
This form is used to instruct HMSA to send or receive information about you to an
individual or organization. The individual or organization sending or receiving
your information will only be allowed to send or receive the information you indicate
on this form. The individual or organization you indicate on part C of this form
will not act as your authorized representative, they may only contact HMSA and make
requests for your information if you specifically indicate so. The individual or
organization you indicate on this form may not initiate appeals or complaints about
your health care coverage through HMSA.
Please note that once your information is disclosed to the person or organization
you indicate in part C of this form, the information in their possession may no
longer be protected by privacy laws. 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 information will be
released. 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 - Request Type:
Select one of the following three options. Only one selection should be chosen per
- Request to Have HMSA Receive Information – Selecting this option allows HMSA to
obtain information from the individual or organization indicated in Part C of this
- Request to Have HMSA Send Information – Selecting this option allows HMSA to send
copies of your information to the individual or organization indicated in Part C
of this form.
- Revoke a Previous Authorization – Selecting this option will cancel a previously
submitted authorization to request or release your information.
Part C - Authorized Person or Organization:
Complete all information about the individual or organization that will represent
you and make requests on your behalf. You may enter information for two individuals
or organizations to act on your behalf.
- Last Name – Enter last name of the individual sending or receiving your information.
- First Name – Enter first name of the individual sending or receiving your information.
- MI – Enter middle initial of the individual sending or receiving your information.
- Address – Enter street address (e.g., "123 Any Street") of the individual
or organization sending or receiving your information.
- City – Enter name of the city (e.g., "Honolulu") of the individual or
organization sending or receiving your information.
- State – Enter state abbreviation (e.g., "HI") of the individual or organization
sending or receiving your information.
- ZIP Code – Enter five-digit ZIP code of the individual or organization sending or
receiving your information. If known, include ZIP +4.
- Organization Name – If sending or receiving your information to/from an organization,
state the name of the organization.
- Telephone – Enter a telephone number with area code.
- Fax – Enter a fax number with area code, if applicable.
Part D - Purpose, Scope, and Expiration:
- Purpose – Indicate the reason that the request or release of your information is
required. If the reason is not for case management/appeals or enrollment, specify
the reason in the "Other" option.
Scope – Certain information described as sensitive information will not be included
in the request or release of your information unless you specifically indicate that
you want it to be included. Choose from the options in the Sensitive Information
section of Part D of this form if you would like sensitive information included
with your information (check all that apply).
In the Description section of Part D of this form, indicate in which portion of
your information should be requested or released. The information can be based on
a timeframe (start date to end date) or an event (e.g., "all information related
to my accident" or "all information related to my surgery on 2/1/2009").
Please be as specific as possible to ensure the correct information is requested
- Expiration – This authorization will be effective beginning on the date it was signed
by the member and will expire on the earliest of the following dates:
- One year from the date the form was signed.
- A date specified by the member (and less than one year).
- A specific event as described by the member (which occurs in less than one year
from the date the form was signed).
- Until the resolution of an appeal you initiated with HMSA.
HMSA will contact you before the form’s expiration date to ask if the authorization
should be extended. If you do not reply, the authorization will expire on the form’s
indicated expiration date.
Part E - 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