This form is used to document the estate executor/administrator or next of kin of the deceased member. This form should be submitted with supporting documents such as a legal document, death certificate, or trust, etc.

The estate executor/administrator is a person who has been appointed by a trust, court, etc. with legal authority to act on behalf of the member. If the member doesn’t have an estate executor/administrator and you are the member’s next of kin, you may submit this form, along with supporting documents to obtain access to the member’s records. Please note that if there’s an estate executor/administrator, their authority will take precedent over next of kin.

Please print legibly and complete the entire form. Incomplete forms won’t be processed and will be returned.

Part A: Member information

Complete all information in this section for the deceased 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.

• Home phone no.*: Enter a home telephone number with area code.

• Work phone no.*: Enter a work telephone number with area code.

• Cell phone no.*: Enter a cell phone number with area code.

• Email: Enter an email address.

• Birthdate: Enter the birth date in this format: mm/dd/yyyy (e.g., 07/15/1990).

• HMSA subscriber no(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.

*At least one phone number is required.

Part B: Estate Executor/Administrator

If the deceased member has an estate executor/administrator, please complete question 2. If the member doesn’t have an executor/administrator, please complete question 3. Provide the appropriate document(s) to support that you’re the estate executor/administrator or next of kin.

Part C: Representative Information

Complete all information about the estate executor/administrator or next of kin (representative) who will represent or act on behalf of the deceased member. One individual or organization per form.

• Last name: Enter the legal last name of the representative.

• First name: Enter the legal first name of the representative.

• MI: Enter the middle initial(s) of the representative.

• Organization name: Enter the name of an organization (e.g., “ABC Inc.”) of the representative. If indicating an organization, include a specific individual within the organization who will represent and act on the member’s behalf, if possible.

• 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.

• Home phone*: Enter a home telephone number with area code.

• Work phone*: Enter a work telephone number with area code.

• Cell phone*: Enter a cell phone number with area code.

• Email: Print the representative’s email address. A unique email address is required for each online user.

• Last four digits of driver license no. or state ID no.: The information will be used to verify the representative’s identity when they contact HMSA on the member’s behalf.

• Birthdate: Provide the representative’s birth date in this format: mm/dd/yyyy (e.g., 07/15/1990). The information will be used to verify the representative’s identity when they contact HMSA on the member’s behalf.

• Relationship to member: Indicate the relationship between the member and the representative (e.g., spouse, daughter-in-law, attorney, etc.).

*At least one phone number is required.

Return the completed form and supporting documents to:

HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860
Fax: 808-952-7580