Coordination of Benefits (COB) Subscriber Questionnaire Form
Print and fill out this form if you or your dependents are covered by more than
one health plan. Mail it to HMSA at the address below.
To avoid delays, please make sure the information is complete.
Answer the question on the top right hand corner of the questionnaire by checking
either the "yes" or "no" box. Read and follow the accompanying instructions carefully.
Section 1. HMSA subscribers must fill in their name, birth date, employment
status, date of retirement (if retired), HMSA member number (located on your HMSA
card), Social Security number, and phone number. Sign and date the form.
Section 2 - Other Coverage Information. Policyholders of the other health
plan must fill in their name, sex, birth date, Social Security number, and relationship
to the HMSA subscriber. Include the other health plan’s name, address and phone
number. Indicate the policyholder’s identification number, employment status, employer,
and date of retirement (if retired).
Indicate the type of coverage of the policyholder along with the effective date
and cancellation date.
List the names (first and last) of other dependents covered by the other plan and
their relationship to you. If there are more than four names, please list the rest
on the back of the form.
Section 3 - Medicare Coverage Information. List the name, Social Security
number, and Medicare number of the Medicare beneficiary. Indicate the type of coverage,
effective date, and reason for Medicare eligibility. If you check "End-Stage Renal
Disease," indicate the initial dialysis date.
Mail this questionnaire to:
Other Party Liability
P.O. Box 860
Honolulu, HI 96808-0860