Request to Restrict Member Information Form
This form is used to request that HMSA restrict the use or disclosure of 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 - Restriction Instructions:
Select the appropriate categories of information you wish to be restricted from
the choices provided. Include a description of the restriction you wish to make.
Please be as specific as possible. If you are enclosing supporting documentation,
briefly describe the supporting documentation.
Part C - Expiration:
This restriction will be effective beginning on the date it was signed by the
member and will expire on the earliest of the following dates:
- Five years from the date the form was signed.
- A date specified by the member (and less than five years).
- A specific event as described by the member (which occurs in less than five years
from the date the form was signed).
HMSA will contact you before the form expires to ask if the restriction should
be extended. If you do not reply, the restriction will expire on the form’s indicated
expiration date and the person(s) or organization(s) indiccated in Part C of the form will no longer act as your authorized representive.
Part D - Your Individual Rights:
This section of the form describes your rights as indicated by applicable state
and/or federal laws.
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