This form is used to request that HMSA amend information about you that’s 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 won’t 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 - Information requested to be amended

Select the appropriate categories of information you wish to be amended from the choices provided. Include a description of the amendment you wish to make and state a reason for the amendment request. Please be as specific as possible. If you’re enclosing supporting documentation, briefly describe the supporting documentation.

Part C - Person or organization to be notified of the amendment

If you’d like us to notify a person or organization of the amendment, please complete the following:

• Last Name – Enter last name of the person to be notified.
• First Name – Enter first name of the person to be notified.
• MI – Enter middle initial of person to be notified.
• Address – Enter street address (e.g., “123 Any Street”) of the person to be notified.
• City – Enter name of the city (e.g., “Honolulu”) of the person to be notified.
• State – Enter state abbreviation (e.g., “HI”) of the person to be notified.
• ZIP Code – Enter five-digit ZIP code of person to be notified. If known, include ZIP +4.
• Organization Name – If notification is to be sent to an organization, state the name of the organization. Organization notifications should include the name and contact information of an individual within the organization.
• Phone Number – Enter a telephone number of the person to be notified with area code.
• Fax Number – Enter a fax number with area code, if applicable, of the person to be notified.

Part E - Your individual rights

This section of the form describes your rights as indicated by applicable state and/or federal laws.

Part F - 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 their relationship 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