2017 HMSA Akamai Advantage Enrollment Change Form


Are you an HMSA Akamai Advantage member and want to switch to another HMSA Akamai Advantage plan? We can help you. Just print and fill out this change form. Mail your completed form to HMSA at the address on the bottom of this page. You may also fax your completed application to 808-948-6343 on Oahu.

You can only make enrollment changes during certain times of the year. In general, enrollment or changes are allowed only during the Annual Election Period, Oct. 15 - Dec. 7, 2016, for an effective date of Jan. 1, 2017, unless you qualify for a special election period. If you miss the Annual Election Period, you must wait until Oct. 15 - Dec. 7, 2017, for an effective date of Jan. 1, 2018. Enrollments need to be approved by the Centers for Medicare and Medicaid Services. Call us at the phone numbers listed in Contact Information section for more information.

Note: If you have a group-sponsored health plan, please contact your benefits administrator before making any changes.

Please complete the entire form so we can process it for you without any delays.

Section 1

  • Write your name, residence address, birth date, gender, mailing address (if different from residence), HMSA member number, daytime telephone number, and email address (optional).
  • Write the name of your primary care provider.
  • Check your current HMSA Akamai Advantage option and what HMSA Akamai Advantage option you would like to change to.
  • Fill in the month you would like your HMSA Akamai Advantage option to start.
  • Check the box to request information in large-print format.

Section 2

  • Please read this important information.
  • Indicate the payment option you want.

Section 3

  • Read sign, and date the form.
  • If the applicant is unable to sign, the applicant’s legal representative must sign and fill in their name, mailing address, and telephone number, and indicate their relationship to the applicant.

Mail change forms to:
HMSA Akamai Advantage Sales
P.O. Box 3500
Honolulu, HI 96811-9983

Please don’t send payment with your change form. Once your enrollment change is approved, we’ll send you a bill every month showing you the premium you owe and the due date. You must pay your monthly premium before the due date. If you indicated on the change form that you want your premium withheld from your Social Security Administration (SSA) or Railroad Retirement Board (RRB) check, we’ll contact you.

Important: If we don’t receive your premiums on time and reasonable attempts have been made to collect them, we’ll have to end your HMSA membership.