Member forms

Member forms

This page links you to the forms Humana Medicare members need most often.

Medicare Advantage Disenrollment Instructions and Form
Both forms below must be completed, signed and returned to Humana for processing.
Medicare Advantage Disenrollment Form(PDF opens in new window)
Special Election Period Questionnaire(PDF opens in new window)

Prescription Drug Plan Disenrollment Instructions and Form
Both forms below must be completed, signed and returned to Humana for processing.
Prescription Drug Plan Disenrollment Form(PDF opens in new window)
Special Election Period Questionnaire(PDF opens in new window)

Medicare Prescription Drug Claim Form Medicare Prescription Drug Claim Form(PDF opens in new window)
Medicare Prescription Drug Claim Form - Spanish (317 Kb)(PDF opens in new window)

Declaration of Prior Prescription Drug Coverage Form Declaration of Prior Prescription Drug Coverage Form(PDF opens in new window)
Declaration of Prior Prescription Drug Coverage Form - Spanish(PDF opens in new window)

Limited Income NET Pharmacy Claim form (135 KB) Download PDF English(PDF opens in new window) (288 KB) Download PDF Spanish(PDF opens in new window)

Medicare Part D Coverage Determination and Redetermination forms Find out about drug coverage determinations and redeterminations and access our forms. Medicare Part D Coverage Determination and Redetermination(opens in new window)

Grievance/Appeal Request Form (42 KB) Download PDFEnglish(PDF opens in new window)  Spanish(PDF opens in new window)

Appointment of Representative Form (1.6 MB) Download PDF English(PDF opens in new window)  Spanish(PDF opens in new window)

You also can get the Appointment of Representative form on CMS's website

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

Notice of Nondiscrimination English(opens in new window)  Spanish(opens in new window)

Multi-language translator service(PDF opens in new window)