Individual privacy rights

Individual rights forms

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 January 2017.
(196 KB) Download PDF
Consent for release of protected health information - English , PDF opens new window
Consent for release of protected health information - Spanish , PDF opens new window

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
Consent for release of protected health information - English, PDF opens new window
Consent for release of protected health information - Spanish, PDF opens new window

This form grants workplace voluntary benefits 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 June 2016.
(72 KB) Download PDF
Consent for release of protected health information - English, PDF opens new window

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 November 2016.
(196 KB) Download PDF
Revocation of consent for release of protected health information - English, PDF opens new window
Revocation of consent for release of protected health information - Spanish, PDF opens new window

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
Revocation of consent for release of protected health information - English, PDF opens new window
Revocation of consent for release of protected health information - Spanish, PDF opens new window

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. This form was last updated in October 2016.
(108 KB) Download PDF
Request for accounting of disclosures - English, PDF opens new window
Request for accounting of disclosures - Spanish, PDF opens new window

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 October 2016.
(108 KB) Download PDF
Request amendment of your protected health information - English, PDF opens new window
Request amendment of your protected health information - Spanish, PDF opens new window

This form requests an inspection or copy of Humana-maintained protected health information about a member. This form was last updated in October 2016.
(208 KB) Download PDF
Request to access protected health information - English, PDF opens new window
Request to access protected health information - Spanish, PDF opens new window

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 October 2016.
(108 KB) Download PDF
Request for restriction of protected health information - English, PDF opens new window
Request for restriction of protected health information - Spanish, PDF opens new window

This form withdraws a previously requested restriction of a member's protected health information. This form was last updated in October 2016.
(104 KB) Download PDF
Request for restriction termination - English, PDF opens new window
Request for restriction termination - Spanish, PDF opens new window

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 a different address. This form was last updated in October 2016.
(108 KB) Download PDF
Request for alternate communications - English, PDF opens new window
Request for alternate communications - Spanish, PDF opens new window

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 October 2016.
(92 KB) Download PDF
HIPAA privacy complaint form - English, PDF opens new window
HIPPA privacy complaint form - Spanish, PDF opens new window