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
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.
- Provider Reconsideration Waiver
- (71.73 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:
- Prior Carrier Deductible Credit Form
- For new members; apply current-year expenses to Humana deductible.
- (28 KB) Download PDF
- English
