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HMAA USE ONLY Policy Enrollment Application 737 Bishop St Suite 1200 Honolulu HI 96813 Phone 808 591-0088 ext. Intentional falsification of material facts or non-disclosure of conditions to secure medical benefits on this application seeking benefits coverage is a violation of Federal and State law and may be punishable by both civil and criminal sanctions. I authorize HMAA to contact the treating physicians or other health care providers or faci.

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