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Plan enrollment

Individual plans

2019 HMSA Individual Plan Application Instructions
2019 HMSA’s Individual Dental Plus Plan Application

Medicare plans

2019 HMSA Akamai Advantage Dual Care (PPO SNP) Application Instructions
2019 HMSA Medicare Advantage Application Instructions

Manage plan


Authorized Representative Form


Acknowledgement of Group Life and AD&D Coverage under Student Plan 19
Coordination of Benefits (COB) Questionnaire
HSTA Travel Reimbursement Benefit Request Form
Individual Tobacco Use Form


HMSA Individual Plan Automatic Payments Form

Medicare plans

2019 HMSA Medicare Advantage Disenrollment Request Form
Appointment of Medicare Representative
HMSA Medicare Advantage Plans Automatic Payments Form


Completing HMSA’s Confidential Communications Form
Request for Identity Password Form

Requests for Information

Authorization to Request or Release Member Information Form
Authorization to Request, Use, or Release Member Psychotherapy Notes Form
Request an Accounting of Disclosures Form
Request Copies of Member Records Form
Request to Amend Member Information Form
Request to Restrict Member Information Form


Dental Claim Form
Essential, Optimal, and Metallic Formulary Coverage Determination Request
HMSA Medicare Advantage Coverage Determination Request
HMSA’s Third-Party Liability Injury/Illness Report Form
Organization Determination (Request for Prior Authorization)
QUEST Integration Formulary Exception Request
Workers’ Compensation Questionnaire Form


Dental Appeals
Disclosure for Conflicts of Interest Evaluation
Medicare Member Appeals
Member Appeals
Request for External Review by an Independent Review Organization


HIPAA Authorization for Release of Information