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• Request an Accounting of Disclosures Form

  Fill out and submit this form to find out who we've shared your personal health information with.

• Appointment of Medicare Representative

  As a Medicare beneficiary, you can appoint a representative to act on your behalf when requesting appeals or prescription drug coverage.

• Legal Document Review Form

  This form lets you appoint legal representative who can access your plan information.

• HIPAA Authorization for Release of Information

  The HIPAA Authorization for Release of Information form allows HMSA to share your information with certain people.

• HIPAA Authorized Representative Form

  This form lets you appoint family or friends who can access your plan information. The form also lets you remove or change your authorized family or friends.

• Request For Services From a Nonparticipating Provider (PPO/HMO)

  HMSA strives to maintain a comprehensive network of participating providers so you can get the care you need.

• Dental Claim Form

  You can ask us to recheck a decision made about your health plan or prescription drug coverage for services or benefits you've received.

• Deceased Member Representative Form

  This form is used to document the estate executor/administrator or next of kin of the deceased member.

• Coordination of Benefits Form

  If you have more than one health care insurer, HMSA will work with them to figure out what your benefits and payments for services are.

• Disclosure for Conflicts of Interest Evaluation

  This form asks you to name any conflicts of interest that may come up in your appeal process.

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