Below is a list of printable forms and information for our Members’ convenience.

  • Enrollment Application – Please confirm eligibility with your Employer before enrolling yourself or a dependent for medical coverage.
  • Information Change Form – Please inform your Employer before submitting a change to your address or other contact information.
  • Unable to Provide Social Security Number – You must complete and submit this form if you or your dependent is unable or unwilling to provide a Social Security Number to HMAA.
  • Authorization for Release of Personal Health Information – Complete and submit this form to authorize the disclosure of your personal health information to another person and/or entity (including your spouse or child over the age of 14).
  • New Member Continuity of Care Notification Form – If you are enrolling with HMAA and are currently receiving care or have been advised to receive healthcare services or medication, complete and submit this form to ensure a smooth transition to our health plan for your continuity of care.

Please confirm your plan coverage with your Employer or refer to your member ID card.

  • Coordination of Benefits (COB) Questionnaire – Please complete and submit this form to provide us with additional information about your other insurance coverage, and avoid potential delays in processing your claims.
  • Third-Party Liability Questionnaire Form – Please complete and submit this form to provide us with additional information about services that may be the responsibility of a third party, and avoid potential delays in processing your claims.
  • Non-Participating Providers – When you visit a non-participating provider, you may need to file the claim with HMAA. Claims for some services rendered by non-participating providers may be paid directly to you with all non-covered charges being your responsibility.
Employee’s Guide to Health Benefits Under COBRA – Provides information on employee rights under COBRA to a temporary extension of employer-provided group health coverage.
  • Prescription Drug Online  – Our pharmacy benefit manager, OptumRx, provides members with free online access to help manage your prescription plan, and their website includes features such as helping you understand your prescription benefits and obtaining maintenance medications through free home delivery. You may also view our Prescription Plan Information.
  • Vision Care Online  – Vision Service Plan (VSP) provides members with free online access to help manage your vision plan and includes various features from understanding your vision benefits to finding the right doctor.
Contact our Customer Service Center to file a complaint. If you are dissatisfied with our privacy practices or think your privacy rights have been violated, you may submit a Privacy Complaint Form.

If you are enrolled in a group health plan and would like to appeal HMAA’s decision, you must do one of the following:

  • For appealing an issue of medical necessity, appropriateness, health care setting, level of care, or effectiveness, or a determination by HMAA that the service or treatment is experimental or investigational and you meet the requirements of Hawaii Revised Statutes Chapter 432E: Request review by an independent review organization (IRO) selected by the Hawaii Insurance Commissioner. You must ask for review by an IRO within 130 days of the decision. The following forms must be submitted to request external review by an IRO.
  • For appealing all other issues: File a lawsuit against HMAA under 29 USC 1132(a) unless your plan is one of the three bulleted types below in which case you must request arbitration before a mutually selected arbitrator:
    • A church plan as defined in 29 USC 2002(33) and no selection has been made in accord with 26 USC 410(d), or
    • A governmental plan as defined in 29 USC 1002(32).
    • A sole proprietor

For further information and requirements, please review HMAA’s Appeals Procedure or contact our Customer Service Center.

We provide language translation services as an added communication support for assistance to our non-English speaking customers while on the phone or face-to-face with one of our employees or participating providers. Written translation services for a particular plan document are available upon request. Please contact us for assistance.

Spanish (Español): Para obtener asistencia en Español, llame al 1-888-941-4622.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-941-4622.
Chinese (中文): 如果需要中文的帮助,请拨打这个号码 1-888-941-4622.

Member Satisfaction Survey – For Members to provide feedback to HMAA at any time. The information collected will enable us to make improvements to our health plans and services, and is kept strictly confidential.

Online Portal Login Effective 01/01/24
User Guide