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Plan enrollment

Individual plans

2023 HMSA Individual Plan Application Instructions
Instructions | View Form
2024 HMSA Individual Plan Application Instructions
Instructions | View Form

Medicare plans

2023 HMSA Akamai Advantage Dual Care (PPO SNP) Application Instructions
Instructions | View Form
2023 HMSA Medicare Advantage Application Instructions
Instructions
2024 HMSA Akamai Advantage Dual Care (PPO SNP) Application Instructions
Instructions | View Form
2024 HMSA Medicare Advantage Application Instructions
Instructions

Manage plan

Authorization

Deceased Member Representative Form
Instructions | View Form
HIPAA Authorized Representative Form
Instructions | View Form
Legal Document Review Form
Instructions | View Form

Benefits

Acknowledgement of Group Life and AD&D Coverage under Student Plan 19
Instructions | View Form
Coordination of Benefits Questionnaire
Instructions | View Form
HSTA Travel Reimbursement Benefit Request Form
Instructions

Individual

HMSA Individual Plan Automatic Payments Form
Instructions | View Form

Medicare plans

Appointment of Medicare Representative
Instructions | View Form
HMSA Medicare Advantage Disenrollment Request Form
Instructions | View Form
HMSA Medicare Advantage Plans Automatic Payments Form
Instructions | View Form

Privacy

Request for Confidential Communications
Instructions | View Form
Request for Identity Password Form
Instructions | View Form

Requests for Information

Authorization to Request, Use, or Release Member Psychotherapy Notes Form
Instructions | View Form
Request an Accounting of Disclosures Form
Instructions | View Form
Request Copies of Member Records
Instructions | View Form
Request to Amend Member Information Form
Instructions | View Form
Request to Restrict Member Information Form
Instructions | View Form

Claims

Dental Claim Form
Instructions | View Form
Essential, Optimal, and Metallic Formulary Coverage Determination Request
Instructions | View Form
HMSA Medicare Advantage Coverage Determination Request
Instructions | View Form
HMSA’s Third-Party Liability Injury/Illness Report Form
Instructions | View Form
Organization Determination (Request for Prior Authorization)
Instructions | View Form
QUEST Integration Formulary Exception Request
Instructions | View Form
Workers’ Compensation Questionnaire Form
Instructions | View Form

Appeals

Commercial Member Form to Appeal
Instructions | View Form
Dental Appeals
Instructions
Disclosure for Conflicts of Interest Evaluation
Instructions | View Form
HMSA Medicare Advantage Member Appeals
Instructions
Medicare Drug Appeal
Instructions
Request for External Review by an Independent Review Organization
Instructions | View Form

Privacy

HIPAA Authorization for Release of Information
Instructions | View Form