Individual rights forms
This form grants Humana and its subsidiaries permission to share your information to a trusted individual(s) that you choose. The form below allows you to choose the level of information to share with the trusted individual. You can specify any and all information, information specific to a treatment or injury, or something different.
Consent for release of protected health information - English
Consent for release of protected health information - Spanish
This form terminates previously granted permission for Humana to release or disclose a member's protected health information to other individuals named on the form.
Revocation of consent for release of protected health information - English
Revocation of consent for release of protected health information - Spanish
This form requests a list of disclosures Humana made of a member's protected health information. Disclosures made for payment and health plan operations are excluded from this process.
Request for accounting of disclosures - English
Request for accounting of disclosures - Spanish
This form requests a correction to Humana-created protected health information that a member feels is inaccurate or incomplete.
Request amendment of your protected health information - English
Request amendment of your protected health information - Spanish
This form requests an inspection or copy of Humana-maintained protected health information about a member.
Request to access protected health information - English
Request to access protected health information - Spanish
This form requests limitation or restriction of disclosures of a member's protected health information to others such as a family member, friend, spouse, doctor, or any other party.
Request for restriction of protected health information - English
Request for restriction of protected health information - Spanish
This form withdraws a previously requested restriction of a member's protected health information.
Request for restriction termination - English
Request for restriction termination - Spanish
This form requests that Humana communicate with a member about protected health information in a different way during life-threatening situations. Examples of alternate means could include telephone, mail, e-mail, or a different address.
Request for alternate communications - English
Request for alternate communications - Spanish
This form documents an issue or concern if a member believes his or her privacy rights may have been violated.
HIPAA privacy complaint form - English
HIPPA privacy complaint form - Spanish