This form is used to request a report of entities that HMSA has disclosed your personal health information to. This form may only be signed by the member or a person with the legal authority to sign for the member.
Please print and complete the form in its entirety. Incomplete forms won’t be processed and will be returned.
Part A - Member information
Complete all information in this section for the member whose records are to be amended. All fields are required.
- Last Name – Enter legal last name as it appears on the HMSA membership card.
- First Name – Enter legal first name as it appears on the HMSA membership card.
- MI – Enter middle initial(s).
- Address – Enter street address (e.g., “123 Any Street”).
- City – Enter name of the city (e.g., “Honolulu”).
- State – Enter state abbreviation (e.g., “HI”).
- ZIP Code – Enter five-digit ZIP code. If known, include ZIP +4.
- Email – Enter an email address, if available.
- Home Phone – Enter a home telephone number with area code.
- Cell Phone – Enter a cell phone number with area code.
- HMSA Subscriber Number(s) – Please include the HMSA subscriber number(s) as indicated on the HMSA membership card. If more than one member ID exists, include all HMSA IDs that this authorization should apply to.
- Birth Date – Enter the birth date in the format mm/dd/yyyy (e.g., 07/15/1990).
Part B - Record dates
Specify the range of dates for the accounting of disclosures you are requesting. Enter date in the format mm/dd/yyyy.
Part C - Record format
You may request copies of the accounting in one of two formats:
- Paper – Records will be copied and provided to you in paper format.
- Electronic – Scanned images of your records will be transferred to a secure, encrypted, and password protected CD or DVD to view on a computer.
Part D - Delivery method
The accounting of disclosures will be delivered to you via one of the following methods:
- Pick Up at an HMSA Office – You’ll be notified when your records are available for pick up at the HMSA location you indicate on the form. A photo ID will be required before the records can be transferred to you.
- Send Via Certified Mail – The records will be sent to you via certified mail to the address listed on your HMSA account.
Part E - Your individual rights
This section of the form describes your rights as indicated by applicable state and/or federal laws.
Part F - Signature
The member should print their name and sign at the bottom of the form. If a person with legal authority other than the member is signing the form, please print the name of the person with legal authority and their relationship to the member, and provide a copy of documentation verifying the legal authority (e.g., a copy of a legal power of attorney).
Return the completed form to the following address:
HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860