HI HMSA 4000-005 2009-2025 free printable template

HMSA MEDICAL/DENTAL PLAN ENROLLMENT FORM PLEASE PRINT OR TYPE IN BLUE OR BLACK INK. REFER TO THE BACK FOR ENROLLMENT INSTRUCTIONS. A Group No. Employer EMPLOYEE DATA FOR HMSA USE ONLY Last Name First Legal M. HMSA. com and click on Find a Doctor. SECTION D - OTHER INSURANCE Check Yes to indicate if you your spouse or any of your dependents are also covered by any other group health plan including HMSA or Medicare. If you check Yes enter the other policy holder s name the other policy holder...

How to fill out HI HMSA 4000-005

How to fill out HI HMSA 4000-005

1. Obtain the HI HMSA 4000-005 form from the HMSA website or your local HMSA office.
2. Fill in your personal information including your name, address, and contact details in the designated sections.
3. Provide your health plan information and member ID as requested on the form.
4. Clearly mark the type of coverage you are applying for or updating.
5. Review the form for any missing information or errors.
6. Sign and date the form at the bottom where indicated.
7. Submit the completed form to HMSA through the specified method outlined in the instructions (mail, email, or online submission).

Who needs HI HMSA 4000-005?

1. Individuals applying for or updating their health insurance coverage with HMSA.
2. Members of HMSA who need to report changes in personal or health plan information.
3. Families seeking to enroll dependents or changes in their coverage status.

People Also Ask about

Is HMSA considered Medicare?

With HMSA Medicare Advantage, you can get an all-in-one plan with medical, prescription drug, dental and vision, and extra benefits beyond Original Medicare .

Is HMSA a Medicaid?

In Hawaii, most of the Medicaid services are delivered through MCO. There are five (5) MCO health plans: AlohaCare, HMSA, Kaiser Permanente, 'Ohana Health Plan, and UnitedHealthcare Community Plan that provides medical and Long Term Services and Support (LTSS) benefits.

How do I file a claim with HMSA?

If you have a complicated claim question or concern, you can call HMSA's Customer Relations at (808)948-6330 on Oahu or 1(800)790-4672 toll-free on the Neighbor Islands.

What does HMSA stand for medical?

Hawaii Medical Service Association. Menu Employers | Providers Find a Doctor Member Login.

What type of insurance is HMSA?

Medicare Advantage It combines hospital (Medicare Part A), medical (Medicare Part B), and sometimes drug (Medicare Part D) benefits. Insurance companies contract with the federal government to offer Medicare Advantage plans.

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What is HI HMSA 4000-005?

HI HMSA 4000-005 is a specific form used for reporting health insurance information in Hawaii.

Who is required to file HI HMSA 4000-005?

Entities that provide health insurance in Hawaii are required to file HI HMSA 4000-005.

How to fill out HI HMSA 4000-005?

To fill out HI HMSA 4000-005, you need to provide accurate health insurance policy details, insured member information, and coverage options as specified on the form.

What is the purpose of HI HMSA 4000-005?

The purpose of HI HMSA 4000-005 is to collect data for health insurance compliance and to ensure proper reporting of health insurance details.

What information must be reported on HI HMSA 4000-005?

The information that must be reported includes policy holder details, coverage start and end dates, type of coverage, and any dependents covered under the policy.