Form Instruction

HMSA Dues Payment Authorization Form

Dues Payment Service is available at no cost to HMSA individual plan members. Most of Hawaii’s major banks, savings and loans, and some credit unions participate with HMSA’s automatic dues payment plan.

To apply for the Dues Payment Service, please print and fill out this form. Mail it to HMSA at the address below.

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

Fill in your name, address, telephone number and HMSA number.
Print the name of your bank or financial institution and the branch you use. Designate a savings or checking account for your monthly deductions and fill in your account number and account holder names.
Attach a voided check or a copy of your savings account statement (with account holder’s name and account information).
Sign and date the form. HMSA member/subscriber must also sign if different from account holder.

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

The process takes about 60 days. Pay your dues your usual way until you receive a confirmation notice from HMSA. At that time, your bank statement will begin showing a deduction for your HMSA dues.

Questions? Please call us.
Oahu – (808) 948-5555
Neighbor Islands – 1 (800) 620-4672 (toll-free)

Notes:

If your spouse or dependents are enrolled in separate individual plans, please complete a form for each HMSA subscriber account.

If you change your health plan or bank account, please complete a new authorization form.

To cancel automatic dues deduction, send us a written request.