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• HMSA Individual Plan Automatic Payments Form

  You can avoid the stress of mailing your premiums to HMSA by signing up for automatic payment.

• HMSA Medicare Advantage Plans Automatic Payments Form

  Have your HMSA Medicare Advantage premiums paid automatically each month when you fill out and submit this form. Most local banks, savings and loans, and credit unions participate.

• Authorization to Request, Use, or Release Member Psychotherapy Notes Form

  This form is used to instruct HMSA to send or receive your psychotherapy notes that we may have to or from an individual or organization.

• HMSA’s Care Access Assistance Program

  HMSA's Care Access Assistance Program makes it easier for HMSA members to see an HMSA participating specialist on another island.

• Attestation Regarding Protected Health Information Potentially Related to Reproductive Health Care

  Attestation regarding a requested use or disclosure of protected health information potentially related to reproductive health care.

• 2025 HMSA Akamai Advantage Dual Care (PPO D-SNP) Application Instructions

  Fill out this form if you've just become eligible for HMSA Akamai Advantage Dual Care or are enrolling during the open enrollment period.

• 2025 HMSA Individual Plan Application Instructions

  Get the application for 2021 HMSA Individual Plan Application here.

• 2025 HMSA Medicare Advantage Application Instructions

  Fill out this form if you've just become eligible for HMSA Medicare Advantage or are enrolling during the open enrollment period.

• HMSA Medicare Advantage Coverage Determination Request

  Fill out this form if you have Medicare Part D and want to know if HMSA will cover a prescription drug and how much it will cost you.

• HMSA Medicare Advantage Member Appeals

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

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