Medicaid documents and forms

Stay organized and find all of the documents and forms you need in one place for your Florida Medicaid plan.

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Find the forms you need quickly

Find your Medicaid documents and forms to manage your plan including:

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Member materials

Do you have any questions about your plan? Check out the Member Handbook, PDF opens new window to find full details of your plan and benefits. Information on Humana Medical Plan, Humana Long-Term Care Plan and Humana Comprehensive Plan can all be found in the member handbook.

If you're looking for a doctor, you can use these directories to see a list of providers you can choose from in your area to get health services.

You can also search for doctors, pharmacies and other healthcare facilities online using our Find a doctor tool.

Region 1

Counties: Escambia, Okaloosa, Santa Rosa and Walton

Provider Directory – English and Spanish (FL counties: Bay, Escambia, Holmes, Okaloosa, Santa Rosa, Walton, and Washington; AL counties: Baldwin, Covington, Escambia, Geneva, Houston, and Mobile; GA counties: Cook, Dekalb, Glynn and Lowndes) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Escambia, Okaloosa, Santa Rosa, Walton, Bay, Holmes and Washington counties) , PDF opens new window

Region 2

Counties: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla and Washington

Provider Directory – English and Spanish (Bay, Calhoun, Dixie, Franklin, Gadsden, Gulf, Hamilton, Holmes, Jackson, Jefferson, Lafayette, Leon, Liberty, Madison, Suwanee, Taylor, Wakulla, Walton, and Washington counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Bay, Calhoun, Franklin, Gadsden, Gulf, Hamilton Holmes, Jackson, Jefferson, Leon, Lafayette, Liberty, Madison, Taylor, Wakulla, Washington, Dixie, Suwanee and Walton counties) , PDF opens new window

Preferred Drug List – English , PDF opens new window

Preferred Drug List – Spanish , PDF opens new window

Region 3

Counties: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee and Union

Provider Directory – English and Spanish (Alachua, Bradford, Citrus, Columbia, and Dixie counties) , PDF opens new window

Provider Directory – English and Spanish (Baker, Clay, Flagler, Hillsborough, Levy, Marion, Putnam, Sumter, Suwanee, and Union counties) , PDF opens new window

Provider Directory – English and Spanish (Polk, Seminole, St. Johns, Taylor and Volusia counties) , PDF opens new window

Provider Directory – English and Spanish (Gilchrist, Hamilton, Hernando, and Lafayette counties) , PDF opens new window

Provider Directory – English and Spanish (Lake, Madison, Orange, Osceola, and Pasco counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwanee and Union counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Baker, Clay, Flagler, Hillsborough, Madison, and Orange) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Osceola, Pasco, Polk, Seminole, St. Johns, Taylor, and Volusia counties) , PDF opens new window

Region 4

Counties: Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia

Provider Directory – English and Spanish (Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia counties) , PDF opens new window

Provider Directory – English and Spanish (Alachua, Bradford, Brevard, Columbia, and Lake) , PDF opens new window

Provider Directory – English and Spanish (Marion, Orange, Putnam, Seminole and Union counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Alachua, Bradford, Brevard, Columbia, Lake, Marion, Orange, Putnam, Seminole and Union counties) , PDF opens new window

Region 5

Counties: Pasco and Pinellas

Provider Directory – English and Spanish (Lake, Pasco, Pinellas, Polk, and Sumter counties) , PDF opens new window

Provider Directory – English and Spanish (Citrus, Hernando, and Hillsborough counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Citrus, Hernando, Hillsborough, Lake, Pasco, Pinellas, Polk and Sumter counties) , PDF opens new window

Region 6

Counties: Hardee, Highlands, Hillsborough, Manatee and Polk

Provider Directory – English and Spanish (Hardee, Highlands, Hillsborough, and Manatee counties) , PDF opens new window

Provider Directory – English and Spanish (Charlotte, Desoto, Glades, Hernando, Lake, Okeechobee, Polk, Sarasota and Sumter counties) , PDF opens new window

Provider Directory – English and Spanish (Orange, Osceola, Pasco, and Pinellas counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Hardee, Highlands, Hillsborough, Manatee and Polk counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Charlotte, DeSoto, Glades, Hernando, Lake, Okeechobee, Orange, Osceola, Pasco, Pinellas, Sarasota and Sumter counties) , PDF opens new window

Region 7

Counties: Brevard, Orange, Osceola and Seminole

Provider Directory – English and Spanish (Brevard, Orange, Osceola and Seminole counties) , PDF opens new window

Provider Directory – English and Spanish (Highlands, Indian River, Lake, Okeechobee, Polk, St. Lucie and Volusia counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Brevard, Orange, Osceola, Seminole, Highlands, Indian River, Lake, Okeechobee, Polk, St. Lucie and Volusia counties) , PDF opens new window

Region 8

Counties: Charlotte, Collier, Desoto, Glades, Hendry, Lee and Sarasota

Provider Directory – English and Spanish (Charlotte, Collier, DeSoto, Glades, Hardee, Hendry, Highlands, Lee and Sarasota counties) , PDF opens new window

Provider Directory – English and Spanish (Hillsborough and Manatee counties) , PDF opens new window

Provider Directory – English and Spanish (Monroe county) , PDF opens new window

Provider Directory – English and Spanish (Okeechobee and Palm Beach counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Charlotte, Collier, DeSoto, Glades, Hendry, Lee and Sarasota counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Broward, Hardee, Highlands, Hillsborough, and Manatee counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Miami-Dade, Monroe, Okeechobee, and Palm Beach counties) , PDF opens new window

Region 9

Counties: Indian River, Martin, Okeechobee, Palm Beach and St. Lucie

Provider Directory – English and Spanish (Palm Beach county) , PDF opens new window

Provider Directory – English and Spanish (Brevard, Glades, Indian River, Martin, Okeechobee and St. Lucie counties) , PDF opens new window

Provider Directory – English and Spanish (Hendry, Highlands, Osceola, and Polk counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Indian River, Martin, Okeechobee, Palm Beach, St. Lucie counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Brevard, Broward, Glades, Hendry, Highlands, Osceola and Polk counties) , PDF opens new window

Region 10

Counties: Broward

Provider Directory – English and Spanish (Broward county) , PDF opens new window

Provider Directory – English and Spanish (Collier and Palm Beach counties) , PDF opens new window

Provider Directory – English and Spanish (Hendry county) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Broward county) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Hendry, Collier, Miami-Dade and Palm Beach counties) , PDF opens new window

Region 11

Counties: Miami-Dade and Monroe

Provider Directory – English and Spanish (Miami-Dade county) , PDF opens new window

Provider Directory – English and Spanish (Collier, Monroe and Palm Beach counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Miami-Dade and Monroe counties) , PDF opens new window

Long-Term Care Provider Directory – English and Spanish (Broward, Collier and Palm Beach counties) , PDF opens new window

Participant Direction Option

Find more information about another option for your long-term care plan—the Participant Direction Option (PDO). The PDO allows you to self-direct your services.

Agency for Health Care Administration (AHCA) PDO Template , opens new window

Agency for Health Care Administration (AHCA) PDO Manual , opens new window

Pharmacy resources

We know it’s important for you to understand which of your medicines are covered. Check the lists below to see which medicines your plan covers.

Preferred Drug List (English, PDF opens new window and Spanish, PDF opens new window)

Cystic Fibrosis Supplemental Drug List – English (1.15 MB) , PDF opens new window

Cystic Fibrosis Supplemental Drug List – Spanish (1.09 KB) , PDF opens new window

Recent changes to Florida Medicaid Drug List , opens new window

Over-the-counter order forms

Your pharmacy benefit lets you order certain over-the-counter (OTC) items through the mail. Use this catalog to look up OTC items you want to order each month. Fill out the form and mail, fax or phone your order to PrescribeIT Rx.

Contact us

Combined Medicaid medical and Long-term care (LTC) OTC form

Over-the-Counter Order Form—English (1.19 MB) , PDF opens new window

Over-the-Counter Order Form—Spanish (838 KB) , PDF opens new window

Prescription drug reimbursement claim form

We hope you don't have to pay for any medicine out of pocket. If it happens, let us know by filling out a reimbursement claim form, and we will try to pay you back.

Fill out the form below to send in a reimbursement claim if you paid out of pocket for a prescription.

Prescription drug reimbursement claim form (611 KB) , PDF opens new window

Legal and privacy notices

These notices provide information about how Humana uses, and when we might share, your personal information.

They also outline the various privacy rights available to you.

Individual privacy rights—English and Spanish

Rights and responsibilities—English

Rights and responsibilities—Spanish

HIPAA privacy notice—English (119 KB) , PDF opens new window

HIPAA Privacy Notice – Spanish (111 KB) , PDF opens new window

Grievance and appeals

We want you to be happy with the care you get from Humana Florida Medicaid. We hope you are getting the best care possible.

If you are not happy with any part of your healthcare plan, Customer Care, your doctor or a facility, you can send in a grievance. You can also appeal a claim or a denied service using this form.

If you are sending an appeal or grievance for another covered member, be sure to fill out an Appointment of Representative form.

Download and return the completed forms to Humana:

Contact us

Grievance/Appeal request form—English (157 KB) , PDF opens new window

Grievance/Appeal request form—Spanish (157 KB) , PDF opens new window

Appointment of Representative form—English/Spanish (157 KB) , PDF opens new window

Your appeal rights (154 KB) , PDF opens new window

Caregiver forms

If you want your caregiver to have access to your health information, you need to fill out the protected health consent form.

You can also find the power of attorney form.

Download below and return the completed forms to:

Humana Medical Plan Customer Care

Contact us

Power of Attorney form (155 KB) , PDF opens new window

Medical

Consent for Release of Medical Information (English and Spanish) , PDF opens new window

Consent for Release of Protected Health Information (2.6 MB) English , PDF opens new window

Access Behavioral Health Consent for Release of PHI (Regions 1 & 2) PDF (195 KB) English , PDF opens new window

Beacon Consent for Release of PHI (Regions 3–11) PDF (152 KB) English , PDF opens new window

Long-term care (LTC)

LTC Consent to Share Health Facts (38 KB) English , PDF opens new window

LTC Consent to Share Health Facts (38 KB) Spanish , PDF opens new window

LTC Consent for Release of Information (965 KB) English , PDF opens new window

LTC Request for Alternative Communications (396 KB) English , PDF opens new window

Living will

Download and complete your living will, fill out an advanced directive or complete an organ donation form.

Living will (152 KB) , PDF opens new window

Advanced directive (151 KB) (Healthcare Surrogate Designation) , PDF opens new window

Organ donation form (152 KB) (Uniform Donor Form) , PDF opens new window

Performance measurement surveys

Let us know how we are doing. We want to make sure we are giving you the best care and services to manage your health. Download performance measurement reports and take our member satisfaction survey.

Guide to HEDIS® measurements , opens new window

State of Health Care Quality Report , opens new window (NCQA website)

Health Risk Assessment (HRA)

If you have a care coordinator or a case manager, they may ask you to complete the HRA originally sent in your welcome kit and listed below.

Take our health risk assessment (877 KB) English, PDF opens new window

Take our health risk assessment (872 KB) Spanish, PDF opens new window

Smartphone benefit information

Humana and SafeLink wireless will provide Medicaid medical members with a free cellphone service and smartphone to call your family, friends and doctors. Plus, you’ll get even more extra services as a member.

Download this fact sheet to learn all the details and how to sign up.

Download SafeLink mobile phone flyer [719 Kb]—English and Spanish, PDF opens new window

Looking for help?

Contact Us

If you have questions, find the number you need to get help and support.

Find a Doctor

Find a doctor, hospital or pharmacy.

Documents & forms

Find the documents and forms you need, including your member handbook.