We want to make sure you receive quality care even if you can’t make decisions about your care on your own. Use this form to appoint a personal representative to act on your behalf for:
- Filing a complaint or grievance on quality of care received, waiting times, customer service, or other issues.
- Filing an appeal if you disagree with our decision to deny or not pay for an item or service, including medical services or prescription medications. (See Medicare Member Appeals for more information.)
- Prescription drug benefits, also known as a Coverage Determination Request.
- Medical benefits, also known as an Organization Determinations (Prior Authorization).
Print and complete this form and attach it to your request form. Mail them to an address listed below.
- Fill in your name and Medicare number.
- Write the name of your appointed representative.
- Sign and date the form. Include your address and telephone number.
- Have the representative write their name, sign and date the form, and fill in their address, telephone number, and relationship to you.
- To waive fees or payment for representation or provider or supplier services, sign and date sections III and IV.
- Mail the form with your request to the appropriate address below.
If you’re filing a complaint, mail this form along with details of your complaint to:
HMSA Customer Relations
P.O. Box 860
Honolulu, HI 96808-0860
If you’re requesting an appeal, mail or fax this form with the appeal request to:
HMSA Member Advocacy & Appeals
P.O. Box 1958
Honolulu, HI 96805-1958
Fax: 808-952-7546 or 808-948-8206 on Oahu
If requesting coverage for a prescription drug, mail this form with the drug review request form to:
Medicare Coverage Determinations and Appeals
MC109 P.O. Box 52000
Phoenix, AZ 85072-2000
If requesting medical care coverage, mail this form and your request to:
HMSA Medical Management Department
P. O. Box 2001
Honolulu, HI 96805-2001
If you have questions about this process, call us so we can help you: