You deserve the best care possible even if you choose to have someone else make health care requests on your behalf. Use this form to appoint a representative for:

• Filing a complaint or grievance on quality of care received, waiting times, customer service, or other issues.
• Filing an appeal if you disagree with our decision to deny or not pay for an item or service, including medical services or prescription medications. (See HMSA Medicare Advantage Member Appeals for more information.)
• Prescription drug benefits, also known as a Coverage Determination Request.
• Medical benefits, also known as an Organization Determinations (Prior Authorization).

Print and complete this form and attach it to your request form.

Instructions

• Fill in your name and Medicare number.
• Section 1: Fill in the name of your appointed representative and your telephone number and address.
• Sign and date Section 1.
• Section 2: Fill in your representative’s name, telephone number, address, and relationship to you.
• Have your representative sign and date Section 2.
• Section 3: If your representative is the provider or supplier, they cannot charge a fee to represent you in filing a grievance, organization determination, or appeal. Your representative also must sign and date this section.
• Section 4: This does not apply to Medicare Advantage. Please leave this section blank.
• The form is good for one year. Please keep a copy for your records in case you need to use it again.
• Mail the form with your request to the appropriate address below.

If you’re filing a complaint, mail this form along with details of your complaint to:

HMSA Customer Relations
P.O. Box 860
Honolulu, HI 96808-0860

If you’re requesting an appeal, mail or fax this form with the appeal request to:

HMSA Member Advocacy & Appeals
P.O. Box 1958
Honolulu, HI 96805-1958

Fax: 808-952-7546 or 808-948-8206 on Oahu

You may also email your appeal to [email protected]. Please note that unencrypted email can be intercepted. To avoid this risk, fax or mail your appeal.

If you’re requesting coverage for a prescription drug, mail this form with the drug review request form to:

Medicare Coverage Determinations and Appeals
MC109 P.O. Box 52000
Phoenix, AZ 85072-2000

If you’re requesting medical care coverage, mail this form and your request to:

HMSA Medical Management Department
P. O. Box 2001
Honolulu, HI 96805-2001

If you have questions about this process, call us so we can help you:

• Oahu: 808-948-6000
• Neighbor Islands or Mainland: 1-800-660-4672 toll-free
• TTY users, call 711.