Individual Privacy Rights

Individual Rights Forms

The following is a brief description of the various individual rights and the appropriate form to invoke one of these rights.

Consent for Release of Protected Health Information
This form grants Humana permission to share your information to a trusted individual(s) that you choose. The form below allows you to choose the level of information to share with the trusted individual. You can specify any and all information, information specific to a treatment or injury, or something different. This form was last updated in November 2009.
(196 KB) Download PDF
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Consent for Release of Protected Health Information
For our CompBenefits members only, we have created a version of this form to use when you would like to grant CompBenefits permission to share your information to a trusted individual(s) that you choose. The form below allows you to choose the level of information to share with the trusted individual. You can specify any and all information, information specific to a treatment, or something different. This form was last updated in July 2009.
(250 KB) Download PDF
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Revocation of Consent for Release of Protected Health Information
This form terminates previously granted permission for Humana to release or disclose a member's protected health information to other individuals named on the form. This form was last updated in April 2008.
(196 KB) Download PDF
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Revocation of Consent for Release of Protected Health Information
For our CompBenefits members only, we have created a version of this form to use when you would like to terminate a previously granted permission for CompBenefits to release or disclose a member’s protected health information to other individuals named on the form. This form was last updated in January 2011.
(196 KB) Download PDF
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Request for Accounting of Disclosures
This form requests a list of disclosures Humana made of a member's protected health information. Disclosures made for payment and health plan operations are excluded from this process. The form was last updated in April 2008.
(108 KB) Download PDF
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Request Amendment to your Protected Health Information
This form requests a correction to Humana-created protected health information that a member feels is inaccurate or incomplete. This form was last updated in April 2008.
(108 KB) Download PDF
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Request to Access Protected Health Information
This form requests an inspection or copy of Humana-maintained protected health information about a member. This form was last updated on April 18, 2008.
(208 KB) Download PDF
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Request for Restriction of Protected Health Information
This form requests limitation or restriction of disclosures of a member's protected health information to others such as a family member, friend, spouse, doctor, or any other party. This form was last updated in April 2008.
(108 KB) Download PDF
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Request for Termination of Restriction
This form withdraws a previously requested restriction of a member's protected health information. The form was last updated in April 2008.
(104 KB) Download PDF
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Request for Alternate Communications
This form requests that Humana communicate with a member about protected health information in a different way during life-threatening situations. Examples of alternate means could include telephone, mail, e-mail, or different address. The form was last updated in April 2009.
(108 KB) Download PDF
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HIPAA Privacy Complaint Form
This form documents an issue or concern if a member believes his or her privacy rights may have been violated. This form was last updated in April 2008.
(92 KB) Download PDF
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