HIPAA Authorization for Release of Information


Section A

  1. Read carefully.
  2. Please clearly print your:
    • Name.
    • Mailing address.
    • Phone number.
    • HMSA subscriber number.

Section B

  1. Read carefully.
  2. If you have objections to what’s being stated, please write them clearly on the line provided.
  3. Print your name clearly. Sign your name and write today’s date.
  4. If you’re a personal representative signing on behalf of the member, print your name clearly. Write your relationship to the member (son, daughter, spouse, etc.).

Once you’ve filled out the form, please mail it with your request to:

Hawaii Insurance Division
Attention: Health Insurance Branch – External Appeals
335 Merchant St., Room 213
Honolulu, HI 96813