This form is used to appoint or revoke an individual or organization to access your health information. The individual or organization indicated in Part B of this form may contact HMSA to access your health information regarding your eligibility, billing, payment status, claims, and medical information HMSA uses to make payment decisions.

Please note that once your information is disclosed to the person or organization you indicate in Part B 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 legibly and complete the entire form. 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 unless specified.

• 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.

• Home phone no.*: Enter a home telephone number with area code.

• Work phone no.*: Enter a work telephone number with area code.

• Cell phone no.*: Enter a cell phone number with area code.

• Birthdate: Enter the birthdate in this format: mm/dd/yyyy (e.g., 07/15/1990).

• HMSA subscriber no(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.

• Email: Enter an email address.

*At least one phone number is required.

Part B: Appointed Representative Information

Select one of the following options. Only one selection should be chosen per form.

• Appoint: Select this option if you’re appointing an individual or organization to contact HMSA.

• Revoke: Select this option to cancel a previously appointed individual or organization.

Complete all information about the individual or organization that you’re appointing. One individual or organization per form.

• Last name: Enter the legal last name of the individual you’re appointing/revoking.

• First name: Enter the legal first name of the individual you’re appointing/revoking.

• MI: Enter the middle initial(s) of the individual you’re appointing/revoking.

• Organization name: Enter the name of an organization (e.g., “ABC Inc.”) that you’re appointing/revoking. If indicating an organization, include a specific individual within the organization if possible.

• 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.

• Home phone*: Enter a home telephone number with area code.

• Work phone*: Enter a work telephone number with area code.

• Cell phone*: Enter a cell phone number with area code.

• Email: Print the appointed individual email address. A unique email address is required for each online user.

• Relationship to member: Indicate the relationship between you and your appointed representative (e.g., spouse, daughter-in-law, attorney, etc.).

• Last four digits of driver license no. or state ID no.: The information will be used to verify the appointed representative’s identity when they contact HMSA on your behalf.

• Birthdate: Provide the individual birthdate in this format: mm/dd/yyyy (e.g., 07/15/1990). The information will be used to verify the appointed representative’s identity when they contact HMSA on your behalf.

*At least one phone number is required.

Part C: Appointment Limitation

Please specify what type of information your appointed representative may access. Indicate by placing a checkmark by each category of information. You may check “All my information” to authorize your appointed representative to access all your information.

Part D: Date Your Appointment Expires

This authorization will be effective on the date it was signed by the member and will expire on the date indicated.

• No expiration: This appointment will be valid from the date the form was signed until you notify HMSA in writing when you’re ready to revoke this authorization.

• A date specified by the member.

• A specific event as described by the member.

Part E: Your Rights

This section of the form describes your rights as indicated by applicable state and/or federal laws.

Part F: Signature

Print your name and sign at the bottom of the form. If a person with legal authority is signing the form, please provide the following information of the person with legal authority:

• Last name: Enter legal last name.

• First name: Enter legal first name.

• 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.

• Home phone*: Enter a home telephone number with area code.

• Work phone*: Enter a work telephone number with area code.

• Cell phone*: Enter a cell phone number with area code.

• Email: Enter an email address. A unique email address is required for each online user.

• Relationship to member**: Indicate the relationship between you and the person with legal authority (e.g., parent, guardian, attorney-in-fact, etc.).

• Last four digits of driver license no. or state id no.: The information will be used to verify the person with legal authority’s identity when they contact HMSA on your behalf.

• Birthdate: Enter the birthdate in this format: mm/dd/yyyy (e.g., 07/15/1990). The information will be used to verify their identify when they contact HMSA on your behalf.

Return the completed form (and supporting documents**) to:

HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860
Fax: 808-952-7580

* At least one phone number is required.
** Please provide a copy of documentation verifying the legal authority (e.g., a copy of a legal power of attorney). If you’ve previously submitted documentation, you don’t need to resubmit it.