Disclosure for Conflicts of Interest Evaluation

Download

If you have a fully insured plan (e.g., non-private, non-federal), and you do not agree with the outcome of your appeal, you can ask to have an independent review organization (IRO), selected by the State Insurance Commissioner’s office, look over your appeal. Three forms are required by the State Insurance Commissioner for an IRO review: The Request for External Review by an Independent Review Organization, the HIPPA Authorization for Release of Information form, and the Disclosure for Conflicts of Interest Evaluation. After you have completed all three forms, mail the forms to the State Insurance Commissioner. This form is provided to ensure that the IRO does not have a conflict of interest.

  1. Please write in the right column the information that’s being requested in the left column.
  2. Sign your name below.
  3. Write today’s date.

Once you’ve filled out the form, please mail it with your request to:

Hawaii Insurance Division
Attention: Health Insurance Branch – External Appeals
335 Merchant St., Room 213
Honolulu, HI 96813

Please click on the link to access the form and form instructions:

Request for External Review by an Independent Review Organization
You can ask to have an independent review organization look over your appeal if you think we made a mistake.

HIPAA Authorization for Release of Information
The HIPAA Authorization for Release of Information form allows HMSA to share your information with certain people.