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• Acknowledgement of Group Life and AD&D Coverage under Student Plan 19

  This form will help you appoint a beneficiary in the event of your accidental death or dismemberment.

• Request to Restrict Member Information Form

  You can request that we restrict the use or disclosure of information about you that we have.

• Request to Amend Member Information Form

  If something about your personal information has changed, use this form to get us up to speed.

• Request for Identity Password Form

  This form is used to ask that HMSA include a password when verifying your identity.

• Request Copies of Member Records

  You can use this form to ask us copies of your records with HMSA.

• Request for Confidential Communications

  This form is used to tell HMSA to send communications to you at a different address or by other means.

• Request an Accounting of Disclosures Form

  Fill out and submit this form to find out who we've shared your personal health information with.

• Legal Document Review Form

  This form lets you appoint legal representative who can access your plan information.

• HIPAA Authorized Representative Form

  This form lets you appoint family or friends who can access your plan information. The form also lets you remove or change your authorized family or friends.

• Deceased Member Representative Form

  This form is used to document the estate executor/administrator or next of kin of the deceased member.

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