Form Instructions

HMSA’s Student Plan 19 Application

To apply for HMSA’s Student Plan 19, please print and fill out this form. Mail it to HMSA at the address below.

To avoid delays, please make sure your application is complete.

1. Fill in your name, phone numbers, mailing address, sex, and birth date.
2. Check “yes” if you have other medical coverage. Fill in the name of your other carrier.
3. Fill in your present or former HMSA subscriber ID.
4. Fill in your Social Security number.
5. Read the agreement, then sign and date the application form.
6. Fill in the name and address of your educational institution.

Please enclose the following with your application:

• Current class schedule showing full-time status.
• Completed USAble Life group life and accidental death and dismemberment beneficiary designation form.
• A check or money order payable to “HMSA” for your first quarter’s dues.

Mail all application materials to:
HMSA/6-AMS
P.O. Box 860
Honolulu, HI 96808-0860

For more information, call (808) 948-5555 on Oahu or 1 (800) 620-4672 toll-free on the Neighbor Islands, Monday through Friday, 8 a.m. - 4 p.m.

Your application is subject to approval by HMSA.