HMSA Individual Plan Automatic Payments Form


Automatic payments are available at no cost to HMSA individual plan members. Most of Hawaii’s major banks, savings and loans, and some credit unions participate with HMSA’s automatic dues payment plan.

To set up automatic payments online, follow these instructions. You’ll need to create a My Account and link your plan. It only takes a few minutes and you’ll need your HMSA membership card and an email address.

If you want to sign up for automatic payments by mail, please print and fill out this form and mail it to HMSA at the address below.

To avoid delays, please make sure your information is complete.

  • Fill in your name, address, telephone number, and HMSA membership number.
  • Print the name of your bank or financial institution and the branch you use. Designate a savings or checking account for your monthly deductions and fill in your account number and account holder names.
  • Attach a voided check or a copy of your savings account statement (with account holder’s name and account information).
  • Sign and date the form. HMSA member/subscriber must also sign if different from account holder.

Mail all materials to:
Attn: Cashiers
P.O. Box 4720
Honolulu, HI 96812-4720

The process takes about 30 days. Pay your dues your usual way until you receive a confirmation notice from HMSA. At that time, your bank statement will begin showing a deduction for your HMSA dues.

Questions? Please call us.
Oahu – 808-948-5555
Neighbor Islands – 1-800-620-4672 (toll-free)


If your spouse or dependents are enrolled in separate individual plans, please complete a form for each HMSA subscriber account.

If you change your health plan or bank account, please complete a new authorization form.

To cancel automatic dues deduction, send us a written request.