graphic: kids

Is Your Child Sick?TM

Emergencies

Medical Emergency:
Poison Control:

Office After Hours:
Call 911
(800) 222-1222

(808) 524-2575

PCP Selection Form for HMSA Members for Patients 18 Years and Older


Check Patient’s HMSA Plan:




Complete this form to select or confirm your or your child's primary care provider (PCP).

PCP Selection for Self

I,
, select or confirm that
is my PCP.

PCP Selection for Child under 18 Years Old

I,
, select or confirm that
is the PCP for my child,


Patient's Phone Number

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

  1. My or my child's PCP, who is in HMSA's network, is the health care provider I select to provide routine health and well-being care and coordinate specialized care.
  2. If I am or 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 I am or my child is an HMSA HMO member and would like to change PCPs, my PCP will send a copy of this form to HMSA Membership Services to complete the change and I should receive a new HMSA membership card within 10 days after this form reaches HMSA. HMSA can enroll me or my child in the health center below and with the PCP above and may contact me for more information.
  4. If I am or my child is a QUEST Integration member and would like to change PCPs, my PCP will send a copy of this form to HMSA Membership Services to complete the change and I should receive a new HMSA membership card within 10 days after this form reaches HMSA. HMSA can enroll me or my child with the PCP above and may contact me for more information.
  5. If I am or my child is an HMSA Akamai Advantage member and would like to change PCPs, my PCP will send a copy of this form to HMSA Membership Services to complete the change and I should receive a new HMSA membership card within 10 days after this form reaches HMSA. HMSA can enroll me or 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, Attn: Membership Services.

The information below applies to QUEST Integration members only.

This document has important information from HMSA QUEST Integration. You can request this written document to be provided to you only in Ilocano, Vietnamese, Chinese (traditional), and Korean. If you need it in another language, you can request to have it read to you in any language. There is no charge. We also offer large print, Braille, sign language, and audio. Call us at 948-6486 or 1 (800) 440-0640 toll-free. TDD/TTY: 1 (877) 447-5990.