Humana members

Whether you're a Humana Medicare member, have an individual or family plan, or get insurance from your employer, you have easy access to documents and forms. Choose the category that best describes your coverage.

Medicare Individual and family Through your employer

Medicare Advantage Disenrollment Instructions and Form

Medicare advantage disenrollment form , PDF opens new window

Special election period questionnaire , PDF opens new window


Prescription Drug Plan Disenrollment Instructions and Form

Prescription drug plan disenrollment form , PDF opens new window

Special election period questionnaire , PDF opens new window


Medicare Prescription Drug Claim Form

Medicare prescription drug claim form - English , PDF opens new window

Medicare prescription drug claim form - Spanish , PDF opens new window


Declaration of Prior Prescription Drug Coverage Form

Declaration of prior prescription drug coverage - English , PDF opens new window

Declaration of prior prescription drug coverage - Spanish , PDF opens new window


Limited income NET pharmacy claim form

Prescription drug claim form for member reimbursement - English , PDF opens new window

Prescription drug claim form for member reimbursement - Spanish , PDF opens new window


Medicare Part D drug coverage determination

There may be times when it is necessary to get approval from Humana before getting a prescription filled. This is called “prior authorization” or Part D coverage determination.

Online request for Part D drug prior authorization , opens new window

Downloadable request forms for Part D prior authorization

Part D drug prior authorization form – English , PDF opens new window

Part D drug prior authorization form - Spanish , PDF opens new window

Learn more about the Part D drug prior authorization process


Grievance, appeal and coverage redetermination

If you have a complaint related to your Humana Part C/Medicare Advantage plan, Part D drug coverage or any aspect of a member's care, we want to hear about it and see how we can help.

You can use this form to:

  • File an appeal for a denied medical service, a medical device or a denied prescription medication.
  • Submit a grievance about your complaint and tell us how you are dissatisfied with your experience.

Please provide complete information, so we can get your issue to the associate who can help you best.

Online request for appeals, complaint and grievances , opens new window

Downloadable request forms for grievance, appeal and coverage redetermination

Appeal, complaint, or grievance form - English , PDF opens new window

Appeal, complaint, or grievance form - Spanish , PDF opens new window

Learn more about the Medicare drug (Part D) coverage redetermination process

Learn more about the Medicare Advantage (Part C) reconsideration process


Appointment of representative form for appeals and grievances

If you are filing an appeal or grievance on behalf of a member, you need an Appointment of Representative (AOR) form or other appropriate legal documentation on file with Humana so that you are authorized to work with Humana on his or her behalf.

Appointment of representative form - English , PDF opens new window

Appointment of representative form - Spanish , PDF opens new window

You also can get the Appointment of Representative form on the Centers for Medicare & Medicaid Services website , opens new window.


Notice of nondiscrimination

Please visit our accessibility page for information on filing a discrimination complaint


Multi-language translator service

Multi-language interpreter services contact information


Member blocking request

Disable access to your secure member website for yourself or a family member

Website blocking request, PDF opens new window

Medical forms

Health benefits claim form , PDF opens new window


Pharmacy forms

Prescription drug claim form - English , PDF opens new window

Prescription drug claim form - Spanish , PDF opens new window

LINET prescription drug claim form - English , PDF opens new window

LINET prescription drug claim form - Spanish , PDF opens new window


Grievance and Appeals Request Form

Grievance/appeal request form - English , PDF opens new window

Grievance/appeal request form - Spanish , PDF opens new window


Appointment of representative form for appeals and grievances

If you are filing an appeal or grievance on behalf of a member, you need an Appointment of Representative (AOR) form or other appropriate legal documentation on file with Humana so that you are authorized to work with Humana on his or her behalf.

Appointment of authorized representative form - English , PDF opens new window

Appointment of authorized representative form - Spanish , PDF opens new window


UMB health savings account forms

HSA beneficiary designation form , PDF opens new window

HSA account closure form , PDF opens new window


Humana mail order pharmacy forms

Humana pharmacy registration order form - English , PDF opens new window

Humana pharmacy registration order form - Spanish , PDF opens new window

Physician fax form – English , PDF opens new window

Physician fax form – Spanish , PDF opens new window


Michelle's Law

Process for continued coverage for full-time students who are on medical leave.

Michelle’s Law – H.R. “2851” , PDF opens new window


Financial protection products (FPP) claim forms

Accident claim filing instructions , PDF opens new window

Critical illness claim filing instructions , PDF opens new window

Supplemental health, hospital indemnity and Healthcare Plus claim filing instructions , PDF opens new window

Individual life claim form , PDF opens new window


Financial protection products (FPP) service forms

Bank draft and credit card authorization , PDF opens new window

FPP cash surrender, dividend, and loan request , PDF opens new window

FPP policy service request , PDF opens new window

FPP payer and premium method change form , PDF opens new window


Member blocking request

Disable the secure member website for yourself or a family member.

Website blocking request , PDF opens new window


Life forms

Individual life claim form - English , PDF opens new window

Life authorization form , PDF opens new window


Privacy

View Humana's privacy rights and download forms. You can also learn more about your rights on the Rights and responsibilities page.

Consent for release of protected health information – English , PDF opens new window

Consent for release of protected health information – Spanish , PDF opens new window

Revocation of consent for release of protected health information – English , PDF opens new window

Revocation of consent for release of protected health information – Spanish , PDF opens new window


Multi-language translator service

Multi-language interpreter services contact information

Medical forms

Health benefits claim form - English , PDF opens new window

Health benefits claim form - Spanish , PDF opens new window


Pharmacy forms

Both forms below must be completed, signed and returned to Humana for processing.

Prescription drug claim form - English , PDF opens new window

Prescription drug claim form - Spanish , PDF opens new window

Limited income NET Pharmacy drug claim form - English , PDF opens new window

Limited income NET Pharmacy drug claim form - Spanish , PDF opens new window


Contraceptive Benefits Plan Form

Applies ONLY to members who received a letter from Humana directing them to this Humana Contraceptive Benefits Plan SPD link. If you are not sure whether this applies to you, please call the customer service phone number on the back of your Humana ID card.

Contraceptive only SPD , PDF opens new window


Grievance and Appeals Request Form

Grievance/appeals request form - English , PDF opens new window

Grievance/appeals request form - Spanish , PDF opens new window


Appointment of representative form for appeals and grievances

If you are filing an appeal or grievance on behalf of a member, you need an Appointment of Representative (AOR) form or other appropriate legal documentation on file with Humana so that you are authorized to work with Humana on his or her behalf.

Appointment of representative form - English , PDF opens new window

Appointment of representative form - Spanish , PDF opens new window


Spending account forms

Personal care and flexible spending accounts claim form - English , PDF opens new window

Direct deposit request - English , PDF opens new window

HSA beneficiary designation , PDF opens new window

HSA account closure , PDF opens new window

Letter of medical necessity - English , PDF opens new window


Humana Pharmacy® mail delivery

Humana Pharmacy registration and order form - English , PDF opens new window

Humana Pharmacy registration and order form - Spanish , PDF opens new window

Physician fax form – English , PDF opens new window

Physician fax form – Spanish , PDF opens new window


Dental forms

Reinstatement/Termination form , PDF opens new window


Life claim forms

Accelerated benefits claim form - English , PDF opens new window

Group life claim form –English , PDF opens new window

Dismemberment benefits claim form - English , PDF opens new window

Waiver of premium initial claim form – English , PDF opens new window

Waiver of premium continuation claim form – English , PDF opens new window

Change of beneficiary form – English , PDF opens new window

Life authorization form , PDF opens new window


Group disability claim forms

Humana short term income Protection claim form , PDF opens new window

Continuing short term disability claim form , PDF opens new window


Prior carrier deductible credit form

For new members apply current year expenses to Humana deductible.

Prior carrier deductible credit form – English , PDF opens new window


Michelle's Law

Process for continued coverage for full-time students who are on medical leave.

Michelle’s Law – H.R. “2851” , PDF opens new window


Member blocking request

Disable the secure member website for yourself or a family member.

Website blocking , PDF opens new window


Privacy

View Humana's privacy rights and download forms. You can also learn more about your rights on the Individual Privacy Rights page.

Consent for release of protected health information – English , PDF opens new window

Consent for release of protected health information – Spanish , PDF opens new window

Revocation of consent for release of protected health information – English , PDF opens new window

Revocation of consent for release of protected health information – Spanish , PDF opens new window


Multi-language translator service

Multi-language interpreter services contact information


State-Specific Documents

View state-specific documents related to Humana’s offerings in your state.

Texas – PPO Member Handbook , PDF opens new window

Texas – HMO Premier Network Handbook , PDF opens new window

Texas – Austin HMOx Network Handbook , PDF opens new window

Texas – Houston HMOx Network Handbook , PDF opens new window

Texas – San Antonio HMOx Network Handbook , PDF opens new window

Texas – Waco HMOx Network Handbook , PDF opens new window

Texas – National POS Handbook , PDF opens new window

Texas – Humana Preferred POS Network Handbook , PDF opens new window


Pre-enrollment disclosure forms

Review a description of plan provisions which may exclude, limit, reduce, modify or terminate your group health insurance coverage.

Medical Pre-Enrollment Disclosure Forms

Specialty Benefits Regulatory and Technical Information Guide – English, PDF opens new window
Specialty Benefits Regulatory and Technical Information Guide – Spanish, PDF opens new window

Humana Whole Life (Secure Life) – English, PDF opens new window
Humana Whole Life (Secure Life) – Spanish, PDF opens new window

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 , opens new window