Documents and Forms

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

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

Member blocking request

Disable the 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

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

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

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

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

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

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

State-Specific Documents

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

Texas – PPO Member 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-Enollment 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