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• Appointment of Medicare Representative

  As a Medicare beneficiary, you can appoint a representative to act on your behalf when requesting appeals or prescription drug coverage.

• 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.

• Coordination of Benefits Form

  If you have more than one health care insurer, HMSA will work with them to figure out what your benefits and payments for services are.

• HMSA Individual Plan Automatic Payments Form

  You can avoid the stress of mailing your premiums to HMSA by signing up for automatic payment.

• HMSA Medicare Advantage Plans Automatic Payments Form

  Have your HMSA Medicare Advantage premiums paid automatically each month when you fill out and submit this form. Most local banks, savings and loans, and credit unions participate.

• Authorization to Request, Use, or Release Member Psychotherapy Notes Form

  This form is used to instruct HMSA to send or receive your psychotherapy notes that we may have to or from an individual or organization.

• Transparency in Coverage: Machine-readable Files

  This transparency in coverage will tell you how to submit claims, get preauthorization, and see if a prescription drug is covered.

• HMSA’s Care Access Assistance Program

  HMSA's Care Access Assistance Program makes it easier for HMSA members to see an HMSA participating specialist on another island.

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