Fill in your name, address, telephone number, and HMSA subscriber ID number.
Attach requested items
Read carefully and attach items 1 through 4.
If your request qualifies for an expedited review, read carefully and sign.
Experimental or investigational attachments
If a determination that the service under review was experimental or investigational, read carefully and attach items 1 and 2.
Once you’ve filled out the form, please mail it with all attachments to:
Hawaii Insurance Division
Attn: Health Insurance Branch – External Appeals
335 Merchant St., Room 213
Honolulu, HI 96813