Form Instructions

Confidential Communications Form

This form is used to instruct HMSA to send communications to you at an alternate address (an address other than the primary address on the account) or by alternative means. Federal law requires that HMSA accommodate reasonable requests for confidential communications when disclosure of all or a part of the information to which the request pertains could endanger you. 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 information will be released. 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 - Request Type:

Select one of the following three options. Only one selection should be chosen per form.

New Request – Select this option if this is a new request for confidential communications.
Update an Existing Request – Select this option if you are modifying information about your existing confidential communication request (e.g., notifying us of a change to your alternate address).
Revoke an Existing Request – Select this option to cancel a previous request for confidential communications. Include the date the confidential communications should end.

Part C - Alternate Communication Information:

You may request to have your communications picked up at a local HMSA office or have your communications mailed to an alternate address you indicate on the form (an address other than the primary address on the account as indicated by the subscriber of the account).

Pick Up All My Communications – Select a location from the options provided. You will be contacted when you have communications to pick up.
Mail All My Communications To My Alternate Address – Enter the following:
- Alternate Mailing Address – Enter your alternate street address (e.g., “123 Any Street”). Your alternate street address cannot be the same as the primary account (subscriber) street address.
- City – Enter name of the city (e.g., “Honolulu”) for your alternate address.
- State – Enter state abbreviation (e.g., “HI”) of your alternate address.
- ZIP Code – Enter five-digit ZIP code of your alternate address. If known, include ZIP +4.

Part D - Your Individual Rights:

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

All correspondence addressed to you will be subject to confidential communications by forwarding to you at the alternate address or by an alternate means as indicated in Part C of this form.
Requests will be accommodated unless the alternative means or location for communication is not reasonable.
An incomplete form will be returned to you for completion and the communication of information to the alternate address may not occur until all of the information on the form is complete.
A request for confidential communications will supersede and take priority over any existing Authorized Representative requests.
Even if you request confidential communications, correspondence may be mailed to the primary (subscriber’s) address until your account information is updated. Also, any checks for services you receive from providers not participating with HMSA could be sent to you but made payable to the subscriber unless you make other payment arrangements with HMSA. These services may be indirectly reflected on the Report to Member (RTM) sent to the subscriber through such communications as the plan deductibles.
If you terminate your request for confidential communications, the restriction will be removed for all of your HMSA correspondence including all confidential member information previously protected.
If either you or the subscriber of the account changes plan subscriber IDs or employers, you will need to resubmit this request.
This request will expire upon the date specified in Part B of this form or 18 months after your benefits coverage has terminated.

Part E - 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