HSTA Travel Reimbursement Benefit Request Form

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To request travel assistance, please print and fill out this form. Fax it to HMSA at the number below.

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

Please check the following boxes as appropriate: “HSTA Travel Reimbursement Benefit,” “Airfare Reimbursement,” “Taxi Reimbursement,” or “Parent/Guardian for a Minor.”

Contact Information: Fill in the contact person’s name and telephone and fax numbers.

Section A: Member information

  • Fill in the member’s HMSA number (from their HMSA card), full name, and birth date.
  • Fill in the companion’s name for patients 17 years old or younger and indicate their relationship to the patient.
  • Fill in the daytime phone number and name of a contact person.

Take the form to the referring provider’s office and have them fill out the rest of the information:

  • Section B – ICD-9-CM Diagnosis code.
  • Section C – Procedure/Service/Treatment information.
  • Section D – Provider information.
  • Section E – Reason for referral to specialist provider.

Fax the completed form to HMSA’s Medical Management department at 808-944-5600 on Oahu.

Once the form is submitted, you’ll be notified whether or not your request meets program guidelines.