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• Legal Document Review Form

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

• HIPAA Authorization for Release of Information

  The HIPAA Authorization for Release of Information form allows HMSA to share your information with certain people.

• 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.

• Request For Services From a Nonparticipating Provider (PPO/HMO)

  HMSA strives to maintain a comprehensive network of participating providers so you can get the care you need.

• Dental Claim Form

  You can ask us to recheck a decision made about your health plan or prescription drug coverage for services or benefits you've received.

• 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.

• Disclosure for Conflicts of Interest Evaluation

  This form asks you to name any conflicts of interest that may come up in your appeal process.

• 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.

• 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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