Special Investigations Referral Form

Required Fields

First name
MI
Last name
Phone number
Email
Address 1
Address 2
City
State
ZIP Code
Are you a Humana member?
YesNo
Member ID

Tell us about the situation you're reporting

Is the member involved a Medicare member?
YesNoI don't know
Is the member involved a Medicaid member?
YesNoI don't know
Subject to be investigated
Provider
Provider name(s)
Patient
Patient name(s)
Agent
Agent name(s)
Other person or group
Other person or group name(s)
Describe the situation
Describe how you became aware of this issue
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