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 (link opens in new window) .

Medical forms

Health Benefits Claim Form - English (200 KB)

Pharmacy forms

Medicare Part D Coverage Determination and Redetermination forms
Find out about drug coverage determinations and redeterminations and access our forms.

Contraceptive Benefits Plan form

Contraceptive-only SPD - English (510 KB)

Applies ONLY to members who received a letter from Humana directing them to this Humana Contraceptive Benefits Plan SPD link. If you are not sure whether this applies to you, please call the customer service phone number on the back of your Humana ID card.

Grievance and Appeals Request forms

Commercial members

Medicare members

You also can get the Appointment of Representative form on CMS's website (link opens in new window) .

Spending Account forms

RightSourceRxSM Prescription Home-Delivery

Dental forms

Refer a dentist (link opens in new window) 

Reinstatement/ Termination Request - English (24 KB)

Life Claim Forms

Workplace Voluntary Benefits Claim Forms

Group Disability Claim Forms

Service forms

Billing forms

Bank Draft and Credit Card Authorization, Kanawha Insurance Company - English (109 KB)

Form 6786 – GCA09JQHH

Michelle's Law

Federal HR 2851 "Michelle's Law" - English (32 KB)

Process for continued coverage for full time students who are on medical leave of absence.

Other

Website blocking - English (53 KB)

Disable the secure member website for yourself or a family member.

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 - English (28 KB)

For new members; apply current-year expenses to Humana deductible.