Use this form to request copies of your records. The form may be signed only by the member or a person with the legal authority to sign for the member.

Please print and complete the form in its entirety. Incomplete forms won’t be processed and will be returned.

Part A - Information of HMSA member whose records are being requested

Complete all information in this section for the member whose records are being requested. All fields are required.

• Last Name: Enter legal last name as it appears on the HMSA membership card.
• First Name: Enter legal first name as it appears on the HMSA membership card.
• MI: Enter middle initial(s).
• Address: Enter street address (for example, “123 Any Street”).
• City: Enter name of the city (for example, “Honolulu”).
• State: Enter state abbreviation (for example, “HI”).
• ZIP Code: Enter five-digit ZIP code. If known, include ZIP +4.
• Email: Enter an email address.
• Home phone no.*: Enter a home telephone number with area code.
• Cellphone no.*: Enter a cellphone number with area code.
• HMSA Subscriber Number(s) – Include the HMSA subscriber number(s) as indicated on the HMSA membership card. If more than one member ID exists, include all HMSA IDs that this authorization applies to.
• Birthdate: Enter the birthdate in the format mm/dd/yyyy (for example, “07/15/1990”).

*At least one phone number is required.

Part B - Request type

Select from the choices provided. If choosing “Other,” be as specific as possible to ensure you receive copies of the correct records.

Part C - Record dates

Specify the range of dates for the records you’re requesting. Enter date in the format mm/dd/yyyy.

Part D - Send my records to a third party

If you’d like your records to be sent to a third party or to an address other than the address in your HMSA account, complete all information about the individual or organization that will receive your records.

• Last Name: Enter legal last name of the recipient.
• First Name: Enter legal first name of the recipient.
• MI: Enter middle initial(s) of the recipient.
• Organization name: Enter the name of an organization (for example, “ABC Inc.”) that will receive your records. If indicating an organization, include a specific individual in the organization, if possible.
• Address: Enter street address (for example, “123 Any Street”).
• City: Enter name of the city (for example, “Honolulu”).
• State: Enter state abbreviation (for example, “HI”).
• ZIP Code: Enter five-digit ZIP code. If known, include ZIP +4.
• Email: Enter an email address.
• Phone no.: Enter a telephone number with area code.
• Fax no.: Enter a fax number with area code.

Part E - Records format

You may request copies of your records in one of the following formats:

• Electronic – Your records will be sent as encrypted files.
• Paper – Records will be copied and provided to you in paper format.
• On-site record inspection – You may request to view your records at an HMSA Center or office.

Part F - Delivery method

Your records will be delivered to you in one of the following methods:

• Certified mail – The records will be sent to you via certified mail to the address in your HMSA account.
• Pick up at an HMSA Center or office – You’ll be notified when your records are available for pick up at the HMSA location you indicate on the form. A photo ID will be required before the records can be transferred to you.
• On-site record inspection – Select an HMSA location where you’d like to inspect your records.

Part G - Your individual rights

This section of the form describes your rights as stated in applicable state and/or federal laws.

Part H - Signature

Print your name and sign the bottom of the form. If a person with legal authority is signing the form, provide the following information of the person with legal authority:

• Last name: Enter the legal last name.
• First name: Enter the legal first name.
• MI: Enter the middle initial(s).
• Address: Enter street address (for example, "123 Any Street").
• City: Enter name of the city (for example, "Honolulu").
• State: Enter state abbreviation (for example, "HI").
• ZIP code: Enter five-digit ZIP code. If known, include ZIP+4.
• Home phone*: Enter a home telephone number with area code.
• Cellphone*: Enter a cellphone number with area code.
• Email: Enter an email address. A unique email address is required for each online user.
• Relationship to member**: Indicate the relationship between you and the person with legal authority (for example, parent, guardian, attorney-in-fact, etc.).
• Last four digits of driver’s license no. or state ID no.: The information will be used to verify the person’s identity when they contact HMSA on your behalf.
• Birthdate: Enter the birthdate in this format: mm/dd/yyyy (for example, “07/15/1990”). The information will be used to verify their identify when they contact HMSA on your behalf.

Send the completed form to the following address:

HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860
Fax: 808-952-7580

*At least one phone number is required.
**Please provide a copy of the document verifying the legal authority (e.g., a copy of a legal power of attorney). If you previously submitted a document, you don’t need to resubmit it.