This form is used to list an individual or an organization as your legal representative or to be listed as the legal representative of the member. This form should be submitted with supporting documents (e.g., Power of Attorney, Advance Health Care Directive, guardianship document, etc.).

The legal representative is authorized to contact HMSA to access the member’s information and make requests on behalf of the member. The information may include 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 B of this form, the information in their possession may no longer be protected by privacy laws. This form may only be signed by you or someone with the legal authority to sign for you.

Please print legibly and complete the entire form. Incomplete forms won’t be processed and will be returned.

Part A: Member information

Complete all information in this section. All fields are required unless specified.

• Last name: Enter legal last name as it appears on the HMSA membership card.

• First name: Enter legal first name as it appears on the HMSA membership card.

• MI: Enter middle initial(s).

• Address: Enter street address (e.g., “123 Any Street”).

• City: Enter name of the city (e.g., “Honolulu”).

• State: Enter state abbreviation (e.g., “HI”).

• ZIP code: Enter five-digit ZIP code. If known, include ZIP+4.

• Home phone no.*: Enter a home telephone number with area code.

• Work phone no.*: Enter a work telephone number with area code.

• Cell phone no.*: Enter a cell phone number with area code.

• Email: Enter an email address.

• Birthdate: Enter the birthdate in this format: mm/dd/yyyy (e.g., 07/15/1990).

• HMSA subscriber no(s).: Please include your HMSA subscriber number(s) as indicated on your HMSA membership card. If you have more than one member ID, include all HMSA IDs that this authorization should apply to.

*At least one phone number is required.

Part B: Legal Representative Information

Complete all information about the legal representative who will represent or act on your behalf. One individual or organization per form.

• Last name: Enter the legal last name.

• First name: Enter the legal first name.

• MI: Enter the middle initial(s).

• Organization name: Enter the name of an organization (e.g., “ABC Inc.”) of the legal representative. If indicating an organization, include a specific individual within the organization who will represent you and act on your behalf, if possible.

• Address: Enter street address (e.g., “123 Any Street”).

• City: Enter name of the city (e.g., “Honolulu”).

• State: Enter state abbreviation (e.g., “HI”).

• ZIP code: Enter five-digit ZIP code. If known, include ZIP+4.

• Home phone*: Enter a home telephone number with area code.

• Work phone*: Enter a work telephone number with area code.

• Cell phone*: Enter a cell phone number with area code.

• Email: A unique email address is required for each online user.

• Last four digits of driver license no. or state ID no.: The information will be used to verify the legal representative’s identity when they contact HMSA on your behalf.

• Birthdate: Provide the birthdate in this format: mm/dd/yyyy (e.g., 07/15/1990). The information will be used to verify the legal representative’s identity when they contact HMSA on your behalf.

• Relationship to you: Indicate the relationship between you and your legal representative (e.g., spouse, daughter-in-law, attorney, etc.).

*At least one phone number is required.

Part C: Supporting Documentation

Please indicate the type of supporting document you’ll provide. Please ensure that you submit the supporting document with the completed and signed form.

Part D: Attestation

If you’re the member and request to list an individual or an organization as your legal representative, please print your name, sign and date the “Member (principal)” section on the left side of the form. If you’re an agent or attorney-in-fact, please print your name, sign, and date the “Attorney-in-fact (agent)” section on the right side of the form.

Return the completed form and supporting documents to:

HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860
Fax: 808-952-7580