This form is for current HMSA Akamai Advantage members who want to disenroll from Akamai Advantage. You must print and fill out this form. Mail your completed form to HMSA at the address on the bottom of this page.
Enrollment changes are possible only at certain times during the year. In general, enrollment or changes are allowed only during the Annual Election Period, Oct. 15 – Dec. 7, 2015, for an effective date of Jan. 1, 2016, unless you qualify for a special election period. If you miss the Annual Election Period, you must wait until Oct. 15 - Dec. 7, 2016, for an effective date of Jan. 1, 2017. Enrollments are subject to approval from the Centers for Medicare and Medicaid Services. Contact our representatives at the phone numbers listed in Contact Information for more information.
Note: If you have coverage through a group-sponsored arrangement, please contact your benefits administrator before making any changes.
All sections of this form must be completed or your enrollment change could be delayed.
- Write your name, Medicare number, telephone number, birth date and gender
- Sign and date the form
- Fill out the second page and check the box next to the statement that applies to you.
Mail change forms to:
HMSA – Membership Services
P.O. Box 860
Honolulu, HI 96808