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