Service Fund Request Form

If you are interested in receiving Service Fund data files or reports please fill out this form and click submit. Humana will then contact and consult you on the available Service Fund information.
 
Instructions: Answer the following questions, then click the Submit button. Your answers will be automatically sent to Humana.
Do you currently receive any Service Fund information?
Yes No
Which of the following best describes your practice?
Primary Care Specialist
Which best describes your business affiliation?
Independent Provider Provider affiliated with an IPA, MSO, or third party consultant
IPA MSO
Provider or IPA Name
Contact Name
Correspondence Address:
Street Address
Street Address
City/State/Zip
Primary Servicing Address:
Street Address
Street Address
City/State/Zip
E-Mail Address
Phone Number
Fax Number
Which of the following would you prefer to receive?
Data Files Reports Unsure

       
Service Fund
This function is available to HMO managed care providers to obtain Service Fund data files and/or reports.
  1. Complete the request form in its entirety.
  2. Submit the form by choosing Submit.

It is electronically submitted to Humana's Service Fund department. Upon receipt of the request, a Humana representative will contact your organization to discuss which Service Fund reports and/or data files your provider organization wishes to receive and in what formats.