RCUH Policies and Procedures
Enclosure: HMSA Authorized Representative Form (optional)
The enclosed Authorized Representative Form is used tell us which family members or friends
you authorize us to share your information with. The individual or organization you list in part C
of this 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 you.
Please return your completed Authorized Representative form to RCUH as soon as possible.
Part A – Member information
• Last Name – Enter legal last name as it appears on your HMSA membership card.
• First Name – Enter legal first name as it appears on your 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.
• Email – Enter an email address, if available.
• Home Phone – Enter a home telephone number with area code.
• Cell Phone – Enter a cell phone number with area code.
• HMSA Subscriber Number(s) – Please include the HMSA subscriber number(s) as
indicated on your HMSA membership card.
• Birth Date – Enter the birth date in the format mm/dd/yyyy (e.g., 07/15/1990).
Part B – Request type
Select one of the following two options. Only one selection should be chosen per form.
1. New Request – Select this option if you’re appointing a new authorized representative
to act on your behalf.
2. Update an Existing Request – Select this option if you’re modifying information about
your current authorized representative (e.g., adding or changing the limitations to the
authorized representative’s authority, or modifying the expiration date for the personal
representative to act on your behalf).
Part C – Information on authorized representative(s):
Complete all information about the individual or organization that will represent you and make
requests on your behalf. You may enter information for two individuals or organizations to act
on your behalf.
• Name of Person or Organization – State the legal first and last name of a person or the
name of an organization you want appointed as your authorized representative. If
indicating an organization, include a specific individual within the organization that will
represent you and act on your behalf, if possible.
• Relationship to Member – Indicate the relationship between you and your authorized
representative (e.g., spouse, daughter-in-law, attorney, etc.).
• Telephone # or Last four digits of Social Security Number – The information will be used
to verify the authorized representative’s identity when they contact HMSA on your
behalf.
Part D – Appointment limitations and expiration:
• Authorization Limitations – Unless specified in part D of this form, your authorized
personal representative will have full access to all of your information. If you would like
to limit the information your authorized representative may access, indicate so by
placing a checkmark in each category of information to restrict. Please note that your
authorized representative won’t have access to the categories of information you
indicate with a checkmark. Leaving this section blank implies no limitations are desired.
• Expiration – This authorization will be effective beginning on the date it was signed by
you and will expire on the earliest of the following dates:
o Five years from the date the form was signed.
o A date specified by you (and less than five years).
o A specific event as described you (which occurs in less than five years from the date
the form was signed).
o Eighteen months after your benefit coverage with HMSA terminates.
Part E – Your individual rights
This section of the form describes your rights as indicated by applicable state and/or federal
laws.
Part F – Signature
Sign at the bottom of the form.
HMSA Authorized Representative Form
The enclosed Authorized Representative Form is used tell us which family members or friends
you authorize us to share your information with. The individual or organization you list in part C
of this 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 you.
Please return your completed Authorized Representative form to RCUH as soon as possible.
Part A – Member information
• Last Name – Enter legal last name as it appears on your HMSA membership card.
• First Name – Enter legal first name as it appears on your 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.
• Email – Enter an email address, if available.
• Home Phone – Enter a home telephone number with area code.
• Cell Phone – Enter a cell phone number with area code.
• HMSA Subscriber Number(s) – Please include the HMSA subscriber number(s) as
indicated on your HMSA membership card.
• Birth Date – Enter the birth date in the format mm/dd/yyyy (e.g., 07/15/1990).
Part B – Request type
Select one of the following two options. Only one selection should be chosen per form.
1. New Request – Select this option if you’re appointing a new authorized representative
to act on your behalf.
2. Update an Existing Request – Select this option if you’re modifying information about
your current authorized representative (e.g., adding or changing the limitations to the
authorized representative’s authority, or modifying the expiration date for the personal
representative to act on your behalf).
Part C – Information on authorized representative(s):
Complete all information about the individual or organization that will represent you and make
requests on your behalf. You may enter information for two individuals or organizations to act
on your behalf.
• Name of Person or Organization – State the legal first and last name of a person or the
name of an organization you want appointed as your authorized representative. If
indicating an organization, include a specific individual within the organization that will
represent you and act on your behalf, if possible.
• Relationship to Member – Indicate the relationship between you and your authorized
representative (e.g., spouse, daughter-in-law, attorney, etc.).
• Telephone # or Last four digits of Social Security Number – The information will be used
to verify the authorized representative’s identity when they contact HMSA on your
behalf.
Part D – Appointment limitations and expiration:
• Authorization Limitations – Unless specified in part D of this form, your authorized
personal representative will have full access to all of your information. If you would like
to limit the information your authorized representative may access, indicate so by
placing a checkmark in each category of information to restrict. Please note that your
authorized representative won’t have access to the categories of information you
indicate with a checkmark. Leaving this section blank implies no limitations are desired.
• Expiration – This authorization will be effective beginning on the date it was signed by
you and will expire on the earliest of the following dates:
o Five years from the date the form was signed.
o A date specified by you (and less than five years).
o A specific event as described you (which occurs in less than five years from the date
the form was signed).
o Eighteen months after your benefit coverage with HMSA terminates.
Part E – Your individual rights
This section of the form describes your rights as indicated by applicable state and/or federal
laws.
Part F – Signature
Sign at the bottom of the form.
HMSA Authorized Representative Form