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Plan enrollment

Individual plans

2017 HMSA Individual Plan Application Instructions
HMSA’s Individual Dental Plus Plan Application

Medicare plans

2017 HMSA Akamai Advantage Application Instructions
2017 HMSA Akamai Advantage Dual Care Application Instructions

Manage plan

Authorization

Authorized Representative Form

Benefits

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

Individual

HMSA Individual Plan Automatic Payments Form

Medicare plans

2017 HMSA Akamai Advantage Disenrollment Request Form
2017 HMSA Akamai Advantage Enrollment Change Form
Appointment of Medicare Representative
HMSA Akamai Advantage Automatic Payments Form

Privacy

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

Claims

Control Formulary Coverage Determination Request
Coverage Determination Request
Dental Claim Form
Essential Formulary 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

Appeals

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

Privacy

HIPAA Authorization for Release of Information