Member Forms
This page links you to the forms Humana members need most often – including medical, dental, life, spending account, and pharmacy documents.
Printable Forms
Note: Our forms are in Portable Document Format (PDF) and require Adobe Reader for viewing and printing. To get the plug-in, visit Adobe's Website to Download Adobe Reader
Medical Forms
- Health Benefits Claim Form
- (200 KB) Download PDF
- English
Pharmacy Forms
- Prescription Drug Claim Form
- General form used to submit pharmacy benefits claims.
- (62 KB) Download PDF
- English
Spending Account Forms
- Personal Care and Flexible Spending Accounts Claim Form
- (1.3 MB) Download PDF
- English
- HSA Beneficiary Designation
- (52 KB) Download PDF
- English
- HSA Account Closure
- (38 KB) Download PDF
- English
- Direct Deposit Request
- (42 KB) Download PDF
- English
RightSourceRxSM Prescription Home-Delivery
Dental Forms
- Reinstatement/ Termination Request
- (24 KB) Download PDF
- English
Life Forms
- Humana short-term income protection—claim form
- (63 KB) Download PDF
- English
- Life Claims
- (116 KB) Download PDF
- English
- Life Waiver Premium
- (160 KB) Download PDF
- English
Michelle's Law
- Federal HR 2851"Michelle's Law"
- Process for continued coverage for full time students who are on medical leave of absence.
- (32 KB) Download PDF
- English
Other
- Website Blocking
- Disable the secure member Website for yourself or a family member.
- (52 KB) Download PDF
- English
- Consent for Release of Protected Health Information
- Allow disclosure of specific information to a person or organization. All California residents should review Humana's No Cost Language Services notice.
- Privacy
- View Humana's privacy rights and forms.
- Individual Privacy Rights Page
- Prior Carrier Deductible Credit Form
- For new members; apply current-year expenses to Humana deductible.
- (28 KB) Download PDF
- English
