Provider Crisis Contact/Location Information

Please complete and submit this form if a disaster or other crisis requires evacuation of your area and/or relocation of your provider office(s). This information is needed so that Humana customer service has current information to provide to Humana members who may call for assistance in locating their providers during emergency situations.

Note to provider groups: A separate form should be completed for each individual provider in the group if the information is not the same for all providers in the group.

Required Required Fields

Office Contact (Office Administrator)

Original Office Address (physical address prior to relocation)

Relocation Office Address (physical address)

Required Relocation Office Address

Relocation Billing Address (If different than Relocation Office Address)

Required

Claims Information

Required Claims Information

Required Has the address changed for claims payment checks?

If yes, what is the new claims payment address?

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