- Complete boxes 1-23. Please type or clearly write the requested information.
- Make sure box 15 contains your subscriber number as it appears on your HMSA membership card.
- Read the authorization to release information in box 36, sign your name, and write today’s date.
- If you want your benefits paid directly to your dentist, sign box 37.
- Ask your dentist to complete boxes 24-35 and 38-58, or attach an itemized bill from your dentist on their letterhead or approved American Dental Association claim form that includes all information requested in those boxes.
- Attach all related Explanation of Benefits statements or other coverage information if applicable.
- Please keep copies of your bills before sending the originals with this claim. Services that are denied for payment will be noted on your Explanation of Benefits. Bills won’t be returned to you even if payment is denied.
Send the completed claim form to:
P.O. Box 1187
Elk Grove Village, IL 60009-1187
Please note claim forms from subscribers must be submitted within one year of the date of service. Claims that cannot be identified because of incomplete subscriber information will be returned.
If you have questions, please call us at 808-948-6440 on Oahu or 1-800-792-4672 toll-free on the neighbor islands.
Or write to:
HMSA Dental Services
P.O. Box 1320
Honolulu, HI 96807-1320