This form is used to instruct HMSA on how to send or receive information about you to an individual or organization. The individual or organization sending or receiving your information will only be allowed to send or receive the information you indicate on this form. The individual or organization you indicate on part C of this form won’t act as your authorized representative, they may only contact HMSA and make requests for your information if you specifically indicate so. The individual or organization you indicate on this form may not initiate appeals or complaints about your health care coverage through HMSA.
Please note that once your information is disclosed to the person or organization you indicate in part C of this form, the information in their possession may no longer be protected by privacy laws. 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 in its entirety. 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 legal last name as it appears on the HMSA membership card.
- First Name – Enter legal first name as it appears on the HMSA membership card.
- MI – Enter middle initial(s).
- Address – Enter street address (e.g., “123 Any Street”).
- City – Enter name of the city (e.g., “Honolulu”).
- State – Enter state abbreviation (e.g., “HI”).
- ZIP Code – Enter five-digit ZIP code. If known, include ZIP +4.
- Email – Enter an email address, if available.
- Home Phone – Enter a home telephone number with area code.
- Cell Phone – Enter a cell phone number with area code.
- HMSA Subscriber Number(s) – Please include the HMSA subscriber number(s) as indicated on the HMSA membership card. If more than one member ID exists, include all HMSA IDs that this authorization should apply to.
- Birth Date – Enter the birth date in the format mm/dd/yyyy (e.g., 07/15/1990).
Part B - Request type
Select one of the following three options. Only one selection should be chosen per form.
- Request to Have HMSA Receive Information – Selecting this option allows HMSA to obtain information from the individual or organization indicated in Part C of this form.
- Request to Have HMSA Send Information – Selecting this option allows HMSA to send copies of your information to the individual or organization indicated in Part C of this form.
- Revoke a Previous Authorization – Selecting this option will cancel a previously submitted authorization to request or release your information.
Part C - Authorized person or organization
Complete all information about the individual or organization that will represent you and make requests on your behalf. You may enter information for two individuals or organizations to act on your behalf.
- Last Name – Enter the last name of the individual sending or receiving your information.
- First Name – Enter the first name of the individual sending or receiving your information.
- MI – Enter the middle initial of the individual sending or receiving your information.
- Address – Enter street address (e.g., “123 Any Street”) of the individual or organization sending or receiving your information.
- City – Enter name of the city (e.g., “Honolulu”) of the individual or organization sending or receiving your information.
- State – Enter state abbreviation (e.g., “HI”) of the individual or organization sending or receiving your information.
- ZIP Code – Enter five-digit ZIP code of the individual or organization sending or receiving your information. If known, include ZIP +4.
- Organization Name – If sending or receiving your information to/from an organization, state the name of the organization.
- Telephone – Enter a telephone number with area code.
- Fax – Enter a fax number with area code, if applicable.
Part D - Purpose, scope, and expiration
- Purpose – Indicate the reason that the request or release of your information is required. If the reason is not for case management/appeals or enrollment, specify the reason in the "Other" option.
Scope – Certain information described as sensitive information won’t be included in the request or release of your information unless you specifically indicate that you want it to be included. Choose from the options in the Sensitive Information section of Part D of this form if you’d like sensitive information included with your information (check all that apply).
In the Description section of Part D of this form, indicate which portion of your information should be requested or released. The information can be based on a timeframe (start date to end date) or an event (e.g., “all information related to my accident” or “all information related to my surgery on 2/1/2009”). Please be as specific as possible to ensure the correct information is requested or released.
Expiration – This authorization will be effective beginning on the date it was signed by the member and will expire on the earliest of the following dates:
- One year from the date the form was signed.
- A date specified by the member (and less than one year).
- A specific event as described by the member (which occurs in less than one year from the date the form was signed).
- Until the resolution of an appeal you initiated with HMSA. HMSA will contact you before the form’s expiration date to ask if the authorization should be extended. If you do not reply, the authorization will expire on the form’s indicated expiration date.
Part E - Signature
The member should print their name and sign at the bottom of the form. If a person with legal authority other than the member is signing the form, please print the name of the person with legal authority and the relationship of the person to the member, and provide a copy of documentation verifying the legal authority (e.g., a copy of a legal power of attorney).
Return the completed form to the following address:
HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860