HMSA’s PPO Conversion Plan Application

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To apply for HMSA’s PPO Conversion Plan, 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.

  1. Fill in your name, address, and phone numbers.
  2. Check “yes” if you have other medical coverage and fill in the name of your carrier.
  3. Fill in your present or former HMSA subscriber number.
  4. Fill in your name, sex, birth date, and Social Security number.
  5. If you’re applying for a family plan, list information for your spouse and each eligible dependent child.
  6. Read the agreement, then sign and date the application.

Please include a check or money order payable to “HMSA” for your first two month’s dues. Additional dues may be required if applying after the 10th of the current month.

Mail all application materials to:
HMSA/6-AMS
P.O. Box 860
Honolulu, HI 96808-0860

For more information, call 808-948-5555 on Oahu or 1-800-620-4672 on the Neighbor Islands, Monday through Friday, 8 a.m. - 4 p.m.

Your application is subject to approval by HMSA.