Form Instructions
HMSA’s Care Access Assistance Program Request Form
To request travel assistance, please print and fill out this form. Fax it to HMSA
at the number below.
To avoid delays, please make sure your request is complete.
Please check the following boxes as appropriate: "Precertification & Care Access
Assistance," "Care Access Assistance Only," and "Parent/Legal Guardian for Minor
Patient."
Contact Information: Fill in the contact person’s name and telephone and fax numbers.
Section A: Member Information
- Fill in the member’s HMSA number (from their HMSA card), full name, and birth date.
- Fill in the companion's name for patients 17 years old or younger and indicate their relationship to the patient.
- Fill in the daytime phone number and name of a contact person.
Take the form to the referring provider’s office and have them fill out the rest
of the information:
- Section B – ICD-9-CM Diagnosis Code.
- Section C – Procedure/Service/Treatment Information.
- Section D – Provider Information.
- Section E – Reason for Referral to Specialist Provider.
Fax the completed form to HMSA’s Medical Management department at (808) 944-5600
on Oahu.
Once the form is submitted, you and your provider will be notified whether or not
your request meets program guidelines.
Please note that changes were made to this form for companion information and check
boxes added to book flights.