This form is used to request that HMSA restrict the use or disclosure of information about you that’s in our possession. 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 - Restriction instructions
Select the appropriate categories of information you wish to be restricted from the choices provided. Include a description of the restriction you wish to make. Please be as specific as possible. If you’re enclosing supporting documentation, briefly describe the supporting documentation.
Part C - Expiration
This restriction will be effective beginning on the date it was signed by the member and will expire on the earliest of the following dates:
- Five years from the date the form was signed.
- A date specified by the member (and less than five years).
- A specific event as described by the member (which occurs in less than five years from the date the form was signed).
- HMSA will contact you before the form expires to ask if the restriction should be extended. If you don’t reply, the restriction will expire on the form’s indicated expiration date and the person(s) or organization(s) indicated in Part C of the form will no longer act as your authorized representive.
Part D - Your individual rights
This section of the form describes your rights as indicated by applicable state and/or federal laws.
Part E - 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