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• HMSA Individual Plan Automatic Payments Form

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

• Organization Determination (Request for Prior Authorization)

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

• Workers’ Compensation Questionnaire Form

  Learn how to fill out the Workers' Compensation Questionnaire form.

• HMSA’s Third-Party Liability Injury/Illness Report Form

  We want to know when you've been hurt in an accident that was caused by someone else. This form lets us know what happened and who's covering your care.

• 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 for External Review by an Independent Review Organization

  You can ask to have an independent review organization look over your appeal if you think we made a mistake.

• Request Copies of Member Records

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

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