2017 HMSA Akamai Advantage Disenrollment Request Form

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Do you want to disenroll from your HMSA Akamai Advantage membership? Please print and fill out this form. Mail your completed form to HMSA at the address on the bottom of this page.

You can only make enrollment changes during certain times of the year. In general, enrollment or changes are allowed only during the Annual Election Period, Oct. 15 – Dec. 7, 2016, for an effective date of Jan. 1, 2017, unless you qualify for a special election period. If you miss the Annual Election Period, you must wait until Oct. 15 - Dec. 7, 2017, for an effective date of Jan. 1, 2018. The Centers for Medicare and Medicaid Services must approve your enrollment. Contact our representatives at the phone numbers listed in Contact Information for more information.

Note: If you have a group-sponsored health plan, please contact your benefits administrator before making any changes.

Please complete the entire form so we can process it for you without any delays.

  • 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