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Completing HMSA’s Confidential Communications Form

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This form lets us know which mailing address you want us to use to receive confidential communications. Federal law requires that HMSA accommodate reasonable requests by members for confidential communications when disclosure of all or a part of the information could endanger them. 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. Incomplete forms won’t 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 your last name as it appears on your HMSA membership card
  • First name: Enter your first name as it appears on your HMSA membership card
  • MI: Enter your middle initial(s)
  • Address: Enter your street address (for example, “123 Any Street”)
  • City: Enter your name of the city (for example, “Honolulu”)
  • State: Enter your state abbreviation (for example, “HI”)
  • ZIP code: Enter your five-digit ZIP code
  • Email: Enter your email address
  • Home phone: Enter your home telephone number including the area code
  • Cell phone: Enter your cell phone number including the area code
  • HMSA subscriber number(s): Please include your HMSA subscriber number(s) shown on your HMSA membership card
  • Birth date: Enter your birth date (for example, “07/15/1990”)

Part B: Request type

Choose one of the following three options.

  • New request: For a new request to begin confidential communications.
  • Update an existing request: If you want to make a change to your current confidential communication request (for example, notifying us of a change to your alternate address).
  • Revoke an existing request: If you don’t need to get confidential communications any more. Make sure you specify when you want the confidential communications to end.

Part C: Attestation of endangerment

Initial this section to verify that confidential communications are necessary for you to avoid endangerment. Federal privacy laws give you the right to request confidential communications to avoid endangerment. Any misrepresentation of your endangerment could lead to fines or other penalties under federal law.

Part D: Alternate communication information

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

  • Pick up my communications: Select a location from the options provided. We’ll contact you at the telephone number you provided in Part A of the form when you have communications for pick up.
  • Mail all my communications to my alternate address. Enter the following:
    • Alternate mailing address: Enter your alternate street address (for example, “123 Any Street”). Your alternate street address can’t be the same as the primary account (subscriber) street address.
    • City: Enter the name of your city (for example, “Honolulu”)
    • State: Enter your state abbreviation (for example, “HI”)
    • ZIP code: Enter your five-digit ZIP code

Part E: Your individual rights

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

Part F: Signature

Print your name and sign at the bottom of the form. If someone with legal authority other than you is signing the form, please print the name of the person with legal authority, their relationship to you, and provide a copy of documentation verifying the legal authority (for example, a copy of a medical power of attorney).

Return the completed form to the following address:

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