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HMSA’s Authorized Representative Form

Posted On October 23, 2018
Posted By Jeong Ku Hwang

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HMSA’s Authorized Representative Form

This form is used tell HMSA which family members or friends HMSA is authorized to share your information with. The individual or organization you list in part C of the form may contact HMSA on your behalf regarding your eligibility, billing, payment status, claims, and medical information HMSA uses to make payment decisions.

Please note that once your information is disclosed to the person or organization you indicate in part C of this form, the information in their possession may no longer be protected by privacy laws. This form may only be signed by the member or a person with the legal authority to sign for the member.

Please complete the form in its entirety and print. Incomplete forms won’t be processed and will be returned.

Return the completed form to the following address:

HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860

Click here to download HMSA’s Authorized Representative Form.

For CCM or CCP referrals of HMSA patients who are incapacitated, please fax the completed Authorized Representative Form with the Care Referral Form to 808-948-8242.