Injury/Illness Report Form

Under the provisions of HMSA plans, medical claims for which another party may be responsible, such as an accident, are not payable by HMSA. Under certain circumstances, however, claims submitted to the responsible party’s insurance carrier and subsequently denied may be considered by HMSA for payment after an Injury/Illness Report Form [PDF] is completed and signed by the member. The completed form should be faxed to HMSA Third Party Liability at 808-952-7987.

For details, see Workers’ Compensation, Third Party Liability, or Motor Vehicle Insurance.

Revision History