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• Organization Determination (Request for Prior Authorization)

  Some services and medical care require a coverage decision by HMSA before they can be covered.

• 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.

• 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 Coverage Determination Request

  Fill out this form if you have Medicare Part D and want to know if HMSA will cover a prescription drug and how much it will cost you.

• HMSA Medicare Advantage Member Appeals

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

• 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.

• 2026 HMSA Akamai Advantage Dual Care (PPO D-SNP) Application Instructions

  Fill out this form if you've just become eligible for HMSA Akamai Advantage Dual Care or are enrolling during the open enrollment period.

• 2026 HMSA Medicare Advantage Application Instructions

  Fill out this form if you've just become eligible for HMSA Medicare Advantage or are enrolling during the open enrollment period.

• 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.

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