Hawaii Medical Service Association Application Agreement
Conditions of Enrollment
Please read carefully. If you agree, sign and date below.
• I understand that if the individuals listed on this application are accepted, I agree: (a) to abide by the constitution, bylaws, and terms and conditions of the plan, and (b) to provide information about my child’s and/or my treatment or condition.
• I agree to the terms set forth in this application and acknowledge that I am signing this application under penalty of perjury, which means I have provided true answers to all the questions on this form to the best of my knowledge.
• I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed).
• I agree that HMSA will set the date that my coverage will begin. I understand that I must pay my monthly premiums in advance.
• I understand that if I’m applying for coverage under a dental plan, there are certain dental services under the plan that may be subject to waiting periods, and I won’t have coverage for those dental services until the waiting periods have been met.
• I understand that HMSA may, at its sole discretion and in accordance with applicable law and regulatory guidance, decline to accept premium or cost-sharing payments made directly or indirectly on my behalf by certain third party payers. These third parties include, but are not limited to commercial entities with potential financial interests, health care providers or suppliers, and other entities from whom HMSA is not required by law to accept payment. I confirm that neither I nor my dependents identified in this application will allow premiums or cost-sharing payments to be made on our behalf by the third party payers identified herein.
I attest to the fact that:
• The dependents (spouse and children) listed on this application are my legal dependents. I understand that HMSA may request proof of this relationship at any time. HMSA may request the following documents: marriage certificate, civil union certificate, birth certificate, adoption documents, legal guardianship papers, or medical power of attorney.
• I understand that HMSA may also request proof of prior or current coverage start and end dates at any time.
• I have enrolled in an exchange-certified dental plan that includes pediatric (children’s) dental benefits as outlined by the ACA.
Consent to Conduct Electronic Transactions
If I’m submitting this Individual Plan Application electronically, then by doing so, I consent to electronic transactions with HMSA generally and consent to electronically enroll myself in an HMSA plan as set out in this agreement specifically. I understand I can withdraw this consent to electronic transactions at any time by so informing HMSA in writing, and thereafter transactions with me will be conducted by paper. Withdrawing consent will not affect the validity of this Individual Plan Application or any other transactions conducted electronically prior to my withdrawal of consent to electronic transactions.
By printing, filling out, and signing this form for a hard copy application, I agree to the terms set forth in this Individual Plan Application and enter into this contract on my behalf (and on behalf of my dependents [spouse and children], if listed).
By signing this Individual Plan Application electronically, it means I acknowledge and agree to the terms of this Individual Plan Application and enter into this contract on my behalf (and on behalf of my dependents [spouse and children] if listed) and so indicate by typing my name below as my electronic signature, executed and adopted by me with the intent to sign this document. In other words, typing my name as an electronic signature indicates I acknowledge and agree to the terms of this Individual Plan Application just as a handwritten signature would on a traditional paper form.