Skip to main content

Pre-qualification form for Special Needs Plan (SNP)

Thank you for applying with Humana. We cannot process your enrollment until we get the following information from you. If we do not receive this information from you, we may have to deny your request to enroll in our plan.

Home health nurse helps woman with walker.

We either did not receive a pre-qualification form or we received an incomplete form.

Please fill out and attach a copy of the pre-qualification form. If you do not have a pre-qualification form, you can download it below. Please only upload the first page.

Pre-qualification form for Special Need Plan (SNP), PDF opens new window
This reference ID is not valid. Refer back to the email you received and click the hyperlink.

Your reference number is:

By selecting “Submit,” I agree that the above information is correct and I understand and agree to the Humana Privacy Policy.