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
- 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
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
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