Documents and Forms
Stay organized and find all of the documents and forms you need in one place for your Humana Dual Fully Integrated D-SNP plan.
Humana Healthy Horizons in Illinois
Consent for release of Protected Health Information
If you want your caregiver to have access to your health information, you need to fill out the protected health consent form. Download and complete the forms and return the completed forms to us.
Consent for release of Protected Health Information – English
Consent for release of Protected Health Information – Spanish
Grievance and appeals
We want you to be happy with the care you get from Humana Healthy Horizons in Illinois. We hope you get 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 also can 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
Grievance/Appeal request form – English
Grievance/Appeal request form – Spanish
Appointment of representative form – English / Spanish
Health Risk Assessments
You can complete your HRA by:
- Calling us at 800-787-3311 (TTY: 711), OR
- Completing it in your MyHumana
opens in new window account online or in the app.
Health Risk Assessment (HRA) – English
Health Risk Assessment (HRA) – Spanish
Legal and privacy notices
Learn more about our real-time reporting requirements and process 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
Living Will
A living will is an important document every adult should complete. A living will lets you clarify in writing what you want family or other healthcare proxy to do if you’re not in a position to make healthcare decisions for yourself
Member Handbook
Do you have any questions about your plan? Check out the Member Handbook to find full details of your plan and benefits. You can find information about the Humana Medical Plan, Humana Long-Term Care Plan, and Humana Comprehensive Plan.
Pharmacy resources
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 CenterWell Pharmacy®
Over-the-counter order form – English
Over-the-counter order form – Spanish
Preferred Drug Lists
Understanding your medicine coverage is important. Check the lists below to see the medicines your plan covers.
Preferred Drug List (PDL) – English
Preferred Drug List (PDL) – Spanish
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 this form to send in a reimbursement claim if you paid out of pocket for a prescription.
Prescription drug reimbursement claim form
Provider directories
You can search for a provider near you using our Find Care
View a printable PDF of your provider directory
To receive a hard copy, call the customer care or member services number printed directly on your member ID card.
Reimbursement for expanded benefits and overnights
We hope you don’t have to pay out of pocket for the benefits you get as a Humana Healthy Horizons in Illinois member. If you do, let us know by filling out a reimbursement claim form, and you may get a refund. Fill out one of the forms below to send a reimbursement claim.
Expanded benefits reimbursement form – English
Expanded benefits reimbursement form – Spanish
Reimbursement for expanded benefits and overnights
We hope you don’t have to pay out of pocket for the benefits you get as a Humana Healthy Horizons in Illinois member. If you do, let us know by filling out a reimbursement claim form, and you may get a refund. Fill out one of the forms below to send a reimbursement claim.
Expanded benefits reimbursement form – English
Expanded benefits reimbursement form – Spanish
Looking for help?
Contact us
If you have questions, find the number you need to get help and support.
Find Care
Find a doctor, hospital, or pharmacy
Documents and forms
Find the documents and forms you need, including your member handbook.