Form Instructions

Request an Accounting of Disclosures Form

This form is used to request a report of entities that HMSA has disclosed your personal health information to. This form may only be signed 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 will not be processed and will be returned.

Part A - Member Information:

Complete all information in this section for the member whose records are to be amended. 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 (e.g., "123 Any Street").
City – Enter name of the city (e.g., "Honolulu").
State – Enter state abbreviation (e.g., "HI").
ZIP Code – Enter five-digit ZIP code. If known, include ZIP +4.
Email – Enter an email address, if available.
Home Phone – Enter a home telephone number with area code.
Cell Phone – Enter a cell phone number with area code.
HMSA Subscriber Number(s) – Please 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 should apply to.
Birth Date – Enter the birth date in the format mm/dd/yyyy (e.g., 07/15/1990).

Part B - Record Dates:

Specify the range of dates for the accounting of disclosures you are requesting. Enter date in the format mm/dd/yyyy.

Part C - Record Format:

You may request copies of the accounting in one of two formats:

Paper – Records will be copied and provided to you in paper format.
Electronic – Scanned images of your records will be transferred to a secure, encrypted, and password protected CD or DVD to view on a computer.

Part D - Delivery Method:

The accounting of disclosures will be delivered to you via one of the following methods:

Pick Up at an HMSA Office – You will 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.
Send Via Certified Mail – The records will be sent to you via certified mail to the address listed on your HMSA account.

Part E - Your Individual Rights:

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

Part F - Signature

The member should print their name and sign at the bottom of the form. If a person with legal authority other than the member is signing the form, please print the name of the person with legal authority and the relationship of the person to the member, and provide a copy of documentation verifying the legal authority (e.g., a copy of a legal power of attorney).

Return the completed form to the following address:

HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860