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
Special Election Period Questionnaire

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
Special Election Period Questionnaire

Medicare Prescription Drug Claim Form Medicare Prescription Drug Claim Form
Medicare Prescription Drug Claim Form - Spanish (317 Kb)

Limited Income NET Pharmacy Claim form (135 KB) Download PDF English (288 KB) Download PDF Spanish

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