Documents and Forms

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 new window

Special election period questionnaire , PDF opens 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 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 coverage determination and redetermination forms

Find out about drug coverage determinations and redeterminations and access our forms.

Enrollee authentication , opens new window

---

Grievance/appeal request form

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

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

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

---

Appointment of representative form

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

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

Appointment of representative form - English , PDF opens new window

Appointment of representative form - Spanish , PDF opens new window

---

Notice of nondiscrimination

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

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

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

---

Multi-language translator service

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

Multi-language interpreter services , 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

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

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

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

Medical forms

Health benefits claim form , 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

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

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

Pysician fax form – English , PDF opens new window

Pysician fax form – Spanish , PDF opens new window

---

Dental forms

Reinstatement/Termination form , PDF opens new window

---

Life claim forms

Individual life claim form - English , PDF opens new window

Accelerated benefits claim form - English , PDF opens new window

Group life 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

---

Workplace voluntary benefits claim forms

Accelerated living claim form - English , PDF opens new window

Accident claim form - English , PDF opens new window

Critical illness claim form –English , PDF opens new window

Hospital indemnity claim form – English , PDF opens new window

Workplace voluntary disability continuation claim form – English , PDF opens new window

Workplace voluntary disability initial claim form – English , PDF opens new window

Workplace voluntary disability maternity claim form – English , PDF opens new window

Health screening benefit claim form –English , PDF opens new window

Cancer wellness claim form – English , PDF opens new window

Healthcare plus claim form – English , PDF opens new window

Lifestyle rewards claim form – English , PDF opens new window

---

Group disability claim forms

Group/care short term disability claim form - English , PDF opens new window

Group/care long term disability claim form - English , PDF opens new window

---

Service forms

Absolute assignment and beneficiary change , PDF opens new window

Payor and premium change form , PDF opens new window

Cash surrender and loan request , PDF opens new window

New York certificate of medical coverage - English , PDF opens new window

Policy service request – English , PDF opens new window

Reinstatement change form – English , PDF opens new window

Cancellation request – English , PDF opens new window

Change of beneficiary form –English , PDF opens new window

---

Billing forms

Bank draft authorization Kanawha Insurance Company – English , 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

---

Life forms

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 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