Submit Power of Attorney and Executor of Estate documentation for a Humana member

Use this form to submit legal documentation that appoints you or another person as healthcare Power of Attorney (POA) for one of our Humana members.

Fields marked with an asterisk * are required.

Enter the Humana member’s information

Remember, the following information is for the Humana member. The Power of Attorney will act on this person's behalf.

Member name

First name
Middle initial
Last name

Member info

Date of birth
Member ID

Member ID can be found on the Member ID card

Member id card image for POA form

Indiana Medicaid members should use their Medicaid ID

Note: Indiana Medicaid members use Medicaid ID for Member ID.

Member contact info

Primary phone number
Email address

Enter the appointee’s information

Remember, the following information is for the person or organization appointed as Power of Attorney for a Humana member.

Is the appointee an
IndividualOrganization
Full name of individual or organization
Organization contact name (if applicable)
Primary phone number
Email
Address
Address2
City
State
ZIP Code

Upload Power of Attorney form.

Please upload your legal documents appointing you as Power of Attorney for one of our members.