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HC5(T) Refund claim form: travel costs to receive NHS treatment. Please read this page before filling in this form - it will help you make this claim correctly.
 Instructions to Employee: This form, to be completed in triplicate, is to be used for the following purposes as provided by the Hawaii Prepaid Health Care Act and
 Hawaii employers who are subject to the Prepaid Health Care Act (PHCA)1 should be familiar with Form HC-5. Employees must sign this form annually if they
 Form HC-5 for 2018 available. Posted on Sep 1, 2017 in News. The Form HC-5 Employee Notification to Employer for Calendar Year 2018 is available here and
 Hawaii's Department of Labor and Industrial Relations Disability Compensation Division recently published Form HC-5 for 2017. Employers must ensure
 Instructions to employer: See employee's selection below and take appropriate action. Keep this completed, signed form and give a copy to the employee.
 HC-5 (Rev.09/17). Use this form if the employee works at least 20 hours per week and: • Works for 2 or more employers** or. • Claims an exemption or waiver
 Instructions to employee: Keep a copy of your completed, signed form for yourself. Give the completed form to your employer. Use this form if any of these apply
 Where may I access forms for administering our health plan with HMAA? and submit “Employee Notification to Employer” (Form HC-5) to the employer.
      
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