Individual Tobacco Use Form


Did you or a dependent stop using tobacco? Tell us by filling out this form, and we’ll waive the tobacco surcharge on your plan premiums.

If you bought your coverage through the Hawai’i Health Connector, you’ll need to go through them to get the surcharge waived.

Here’s what you need to include:

  • Your first and last name
  • Subscriber ID number
  • Your birth date
  • Your current contact information
  • Who you’re submitting for (example: yourself, a dependent, etc.)
  • The member’s first and last names, and their birth date
  • Who isn’t/is using tobacco
    • If you select “no,” tell us how you quit
  • The subscriber’s signature, name, and the date the form was filled out

When you’ve finished the form, you can mail it to:

Attn: Membership Services
818 Keeaumoku St.
Honolulu, HI 96814

Or fax if you’re on Oahu: