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• Request to Amend Member Information Form

  If something about your personal information has changed, use this form to get us up to speed.

• Request to Restrict Member Information Form

  You can request that we restrict the use or disclosure of information about you that we have.

• HMSA Individual Plan Automatic Payments Form

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

• Coordination of Benefits (COB) Questionnaire

  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.

• HMSA Akamai Advantage Automatic Payments Form

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

• 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.

• Acknowledgement of Group Life and AD&D Coverage under Student Plan 19

  This form will help you appoint a beneficiary in the event of your accidental death or dismemberment.

• HMSA’s Third-Party Liability Injury/Illness Report Form

  We want to know when you’ve been hurt in an accident that was caused by someone else. This form lets us know what happened and who’s covering your care.

• 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.

• HSTA Travel Reimbursement Benefit Request Form

  Find out if you qualify for HSTA travel reimbursement by filling out this form.