Humana member forms.

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
Limited Income NET Pharmacy Claim Form
(650 KB) Download PDF
English
Medicare Part D Coverage Determination and Redetermination Forms

Find out about drug coverage determinations and redeterminations and access our forms.

Medicare Part D Coverage Determination and Redetermination

Grievance and Appeals Request Forms

Commercial Members
Grievance/Appeal Request Form
(135 KB) Download PDF
English
Appointment of Representative Form
(9 KB) Download PDF
English
Medicare Members
Grievance/Appeal Request Form
(42 KB) Download PDF
English
Appointment of Representative Form
(1.6 MB) Download PDF
English

You also can get the Appointment of Representative form on CMS's website.

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
Letter of Medical Necessity
(20 KB) Download PDF
English

RightSourceRx SM Prescription Home-Delivery

Registration & Prescription Order Form
(620 KB) Download PDF
English | Spanish
Physician Fax Form
(76 KB) Download PDF
English | Spanish

Dental Forms

Refer a Dentist

Reinstatement/ Termination Request
(24 KB) Download PDF
English

Disability, Life, and Workplace Voluntary Benefits Forms

Claims Forms
Group/Core Short Term Disability Claim Form (To use this claim form your policy number should start with a K)
(76 KB) Download PDF
English
Group /Core Long Term Disability Claim Form (To use this claim form your policy number should start with a K)
(88 KB) Download PDF
English
Accident Claim Form
Form – GNHH5LOHH
(124 KB) Download PDF
English
Cancer Wellness Claim Form
Form – GNHH5M0HH
(124 KB) Download PDF
English
Cash Cancer Claim Form
Form 6740 – GCA09JIHH
(124 KB) Download PDF
English
Critical Illness & Supplemental Health Wellness Claim Form
Form – GNHH5LZHH
(124 KB) Download PDF
English
Critical Illness Claim Form
Form 6781 – GCA09JJHH
(124 KB) Download PDF
English
Healthcare Plus Wellness Claim Form
Form – GNHH5LZHH
(124 KB) Download PDF
English
Individual Life Claim Form
Form 6784 – GCA09JHHH
(124 KB) Download PDF
English
Initial Waiver of Premium Claim Form
(462 KB) Download PDF
English
Waiver of Premium Continuation Claim Form
(429 KB) Download PDF
English
Supplemental Health, Hospital Indemnity, Healthcare Plus Claim Form
Form 6783 – GCA09JKHH
(123 KB) Download PDF
English
Workplace Voluntary Disability - Initial Claim Form (To use this claim form your policy number should be 10 digits)
Form – GNHH5M6HH
(124 KB) Download PDF
English
Workplace Voluntary Disability - Extension Claim Form (To use this claim form your policy number should be 10 digits)
Form – GNHH5M0HH
(124 KB) Download PDF
English
Workplace Voluntary Disability - Maternity Claim Form (To use this claim form your policy number should be 10 digits)
Form – GNHH5M8HH
(124 KB) Download PDF
English
Financial Protection Products Forms (FPP)
Individual Life Claim Form
Form 6784 - GCA09JHHH
(380 KB) Download PDF
English
Cash Cancer Claim Form
Form 6740 - GNHH5LTHH
(453 KB) Download PDF
English
Critical Illness Claim Form
Form 6781 - GNHH5M2HH
(439 KB) Download PDF
English
Supplemental Health, Hospital Indemnity, and Healthcare Plus Claim Form
Form 6783 - GNHH5M5HH
(413 KB) Download PDF
English
Service Forms
Coverage Change Form
Form 6106 – GCA09JLHH
(151 KB) Download PDF
English
Policy Service Request
Form 6016 – GCA09JMHH
(185 KB) Download PDF
English
Reinstatement Change Form
Form 6792 – GCA09JNHH
(151 KB) Download PDF
English
Cancellation Request
Form 6789 – GCA09JOHH
(102 KB) Download PDF
English
Change of Beneficiary Form
Form 6042 – GCA09JPHH
(28 KB) Download PDF
English
Billing Forms
Bank Draft Authorization, Kanawha Insurance Company
Form 6786 – GCA09JQHH
(109 KB) Download PDF
English
Bank Draft and Credit Card Authorization, Kanawha Insurance Company
Form 6780 – GCA09JRHH
(115 KB) Download PDF
English
Life Forms
Humana Short Term Income Protection Claim Forms (To use this claim form your policy number should be 9 digits)
(63 KB) Download PDF
English
Humana Group Life Claim Forms
(116 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.
(53 KB) Download PDF
English

Privacy

View Humana's privacy rights and download forms, including:

  • Consent for Release of Protected Health Information
  • Revocation of Consent for Release of Protected Health Information
  • Individual Privacy Rights Page
Prior Carrier Deductible Credit Form
For new members; apply current-year expenses to Humana deductible.
(28 KB) Download PDF
English