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PCP Selection Form for HMSA Members Under 18


Check subscriber’s HMSA plan:




Complete this form to select or confirm your child's primary care provider (PCP). Children with the same HMSA subscriber or authorized representative and selecting the same PCP may be included on one form.

PCP selection for child(ren) under 18 years of age

I,
, select or confirm that
is the PCP for my child(ren):

Print each child's name as it appears on the HMSA membership card:















Patient's Phone Number

By completing and signing this form, I attest to the following:

  1. My child(ren)'s PCP, who's in HMSA's network, is the health care provider I select to provide routine health and well-being care and coordinate specialized care.
  2. I understand that if my child is an HMSA preferred provider organization (PPO) member or a member of HMSA Federal Plan 87, I have a choice of PCPs in HMSA's network and I may change PCPs at any time.
  3. If my child is an HMSA health maintenance organization (HMO) member and would like to change PCPs, my child's PCP will send a copy of this form to HMSA Membership Services to complete the change. I should receive a new HMSA membership card within 10 business days after this form reaches HMSA. HMSA can enroll my child in the health center below and with the PCP above and may contact me for more information.
  4. If my child is a QUEST Integration member and would like to change PCPs, my child's PCP will send a copy of this form to HMSA Membership Services to complete the change. I should receive a new HMSA membership card within 10 business days after this form reaches HMSA. HMSA can enroll my child with the PCP above and may contact me for more information.
  5. If my child is an HMSA Akamai Advantage member and would like to change PCPs, my child's PCP will send a copy of this form to HMSA Membership Services to complete the change. I should receive a new HMSA membership card within 10 business days after this form reaches HMSA. HMSA can enroll my child with the PCP above and may contact me for more information.


Providers, keep a copy of this form for your records.

PPO members don't need to submit this form to HMSA.

For HMO, QUEST Integration, and HMSA Akamai Advantage members: fax the completed form to 948-8235 on Oahu or 1 (800) 540-1668 toll-free on the Neighbor Islands, Attn: Membership Services.