HIPAA Authorization for Release of Information

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If you have a fully insured plan (e.g., non-private, non-federal), and you do not agree with the outcome of your appeal, you can ask to have an independent review organization (IRO), selected by the State Insurance Commissioner’s office, look over your appeal. Three forms are required by the State Insurance Commissioner for an IRO review: The Request for External Review by an Independent Review Organization, the HIPPA Authorization for Release of Information form, and the Disclosure for Conflicts of Interest Evaluation. After you have completed all three forms, mail the forms to the State Insurance Commissioner. This form allows your providers to disclose non-public personal health information to the IRO.

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

Please click on the link to access the form and form instructions:

Request for External Review by an Independent Review Organization
You can ask to have an independent review organization look over your appeal if you think we made a mistake.

Disclosure for Conflicts of Interest Evaluation
This form asks you to name any conflicts of interest that may come up in your appeal process.