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Individual Privacy Rights Forms
- Consent for Release of Personal and Health Information - This form grants Humana permission to release and/or disclose a member's personal and health information to other individuals that are named within the form. For return address information, please contact our Customer Service Department by dialing the toll-free number on the back of your member identification card (Last updated July 13, 2005).
- Revocation of Consent for Release of Personal and Health Information - This form terminates the permission given to Humana previously to release and/or disclose a member's personal and health information to other individuals that are named within the form. For return address information, please contact our Customer Service Department by dialing the toll-free number on the back of your member identification card. (Last updated July 13, 2005).
- Request for Accounting of Disclosures - This form is used to request a list of disclosures of a member's personal and health information made by Humana. Disclosures made for payment and health plan operations are excluded from this process (Last updated July 13, 2005).
- Request Amendment to your Protected Health Information - This form is used to request a correction of a member's personal and health information created by Humana that a member feels is inaccurate or incomplete (Last updated July 13, 2005 ).
- Request to Access Personal and Health Information - This form is used to request an inspection and/or obtain a copy of a member's personal and health information maintained by Humana (Last updated March 31, 2005).
- Request for Restriction - This form is used to request a limitation or restriction of disclosures of a member's personal and health information to others such as a family member, friend, spouse or physician or any other party (Last updated July 13, 2005).
- Request for Termination of Restriction - This form is used to withdraw a previously requested restriction of a member's personal and health information (Last updated July 13, 2005).
- Request for Alternate Communications - This form is used to request an alternate means by which Humana can communicate with a member concerning their personal and health information in life threatening situations. Examples of alternate means could include telephone, mail, e-mail, or different address. (Last updated July 13, 2005 ).
- HIPAA Privacy Complaint Form - This form is used to document an issue or concern regarding a member's belief that their privacy rights may have been violated (Last updated July 13, 2005 ).
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