This form is used to appoint or revoke an individual or organization to act on your behalf. The individual or organization indicated in part C of this form may contact HMSA and make requests on your behalf regarding your eligibility, billing, payment status, claims, and medical information HMSA uses to make payment decisions. They may also 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 complete the form in its entirety and print. 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.
New Request – Select this option if you’re appointing a new authorized representative to act on your behalf.
Update an Existing Request – Select this option if you’re modifying information about your current authorized representative (e.g., adding or changing the limitations to the authorized representative’s authority, or modifying the expiration date for the personal representative to act on your behalf).
Revoke an Existing Request – Select this option to cancel a previously appointed authorized representative.
Part C - Information on authorized representative(s):
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.
Name of Person or Organization – State the legal first and last name of a person or the name of an organization you want appointed as your authorized representative. If indicating an organization, include a specific individual within the organization that will represent you and act on your behalf, if possible.
Relationship to Member – Indicate the relationship between you and your authorized representative (e.g., spouse, daughter-in-law, attorney, etc.).
Driver’s License # or Last four digits of Social Security Number – The information will be used to verify the authorized representative’s identity when they contact HMSA on your behalf.
Part D - Appointment limitations and expiration:
Authorization Limitations – Unless specified in part D of this form, your authorized personal representative will have full access to all of your information. If you would like to limit the information your authorized representative may access, indicate so by placing a checkmark in each category of information to restrict. Please note that your authorized representative won’t have access to the categories of information you indicate with a checkmark. Leaving this section blank implies no limitations are desired.
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:
Five years from the date the form was signed.
A date specified by the member (and less than five years).
A specific event as described by the member (which occurs in less than five years from the date the form was signed).
Eighteen months after your benefit coverage with HMSA terminates.
HMSA will contact you before the form expires to ask if the authorization should be extended. If you do not reply, the authorization will expire on the form’s indicated expiration date and the person(s) or organization(s) indicated in part C of the form will no longer act as your authorized representative.
Part E - Your individual rights
This section of the form describes your rights as indicated by applicable state and/or federal laws.
Part F - 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