Member forms

Member forms

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

Limited Income NET Pharmacy Claim form
(650 KB) Download PDF
English

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

Grievance/Appeal Request Form
(42 KB) Download PDF
English

Appointment of Representative Form
(1.6 MB) Download PDF
English

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