This form lets us know which mailing address to send you 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 be signed only 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: Information of member requesting confidential communications

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 no.: Enter your home telephone number including the area code.
• Cellphone no.: Enter your cellphone number including the area code.
• HMSA subscriber no(s).: Please include your HMSA subscriber number(s) shown on your HMSA membership card.
• Birthdate: Enter your birthdate (for example, “/15/1990”).

Part B: Request type

Choose one of the following options.

• New request: To begin confidential communications.
• Update an existing request: If you want to make a change to your current confidential communication request (e.g., notifying us of a change to your alternate address).
• Revoke an existing request: If you don’t need to get confidential communications anymore. Make sure to 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. Since 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.

Part D: Alternate communication information

You may request 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). Or, you may request to pick up your communications at an HMSA Center or office

• Mail all my communications to my alternate address. Enter the following:
  • 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.
• 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 ready to pick up.

Part E: Expiration

This request will expire on the date indicated.

Part F: Your individual rights

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

Part G: Signature

Print your name and sign at the bottom of the form. *If you are less than 18 years old, a custodial parent or legal guardian must complete the following information and sign the form. **If you are less than 18 years old (ages 14-17) and meet one of the exception requirements listed on the form, no parent/legal representative information is required.

• Parent/Legal representative’s first and last names: Enter the legal first and last names.
• Parent/Legal representative’s email: Enter an email address.
• Parent/Legal representative’s signature: Signature.

*Please provide a copy of documentation verifying the legal authority (e.g., copy of birth certificate in support of your parental status, power of attorney). If you previously submitted documentation, you don’t need to resubmit it.
**Select one or more of the conditions that apply to you.

Return the completed form to:

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