Form Instructions

Request to Revoke Authorization Form

With this form, you revoke, or cancel, authorization you’ve previously given to another adult or organization to access your confidential HMSA member information.

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 revoking the authorization

In this section, print your name (or the name of the person who “owns” the confidential member information), the HMSA number, birth date, and telephone number.

Part C: Description of authorization revoked

Attach a copy of the original authorization or describe the identifying details, such as the dates and purpose of the authorization.
Print the names of the people or organizations for whom you want authorization revoked, or canceled.
Note: These entities will no longer have access to your confidential member information. However, revoking authorization now doesn’t affect actions taken by HMSA during the previous authorization period.
To revoke authorization for more than two people or organizations, please complete and attach another form.
Print your name, sign and date the form.

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

Form Instructions

Request to Revoke Authorization Form

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