Individual rights forms
This form grants Humana and its subsidiaries 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.
, PDF opens new window
, 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.
, PDF opens new window
, 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.
, PDF opens new window
, PDF opens new window
This form requests a correction to Humana-created protected health information that a member feels is inaccurate or incomplete.
, PDF opens new window
, PDF opens new window
This form requests an inspection or copy of Humana-maintained protected health information about a member.
, PDF opens new window
, 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.
, PDF opens new window
, PDF opens new window
This form withdraws a previously requested restriction of a member's protected health information.
, PDF opens new window
, 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.
, PDF opens new window
, PDF opens new window
This form documents an issue or concern if a member believes his or her privacy rights may have been violated.
, PDF opens new window
, PDF opens new window