Member Forms

Printable Forms

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

Spending Account Forms Personal Care and Flexible Spending Accounts Claim Form (112 KB) Download PDF English HSA Beneficiary Designation (52 KB) Download PDF English HSA Account Closure (38 KB) Download PDF English Direct Deposit Request (498 KB) Download PDF English

Dental & Life Forms Refer a Dentist Life Claims (116 KB) Download PDF English Life Waiver Premium (160 KB) Download PDF English Reinstatement/ Termination Request (24 KB) Download PDF English Pharmacy Forms Prescription Drug Claim Form General form used to submit pharmacy benefits claims. (62 KB) Download PDF English

RightSourceRxSM Prescription Home-Delivery Registration & Prescription Order Form (620 KB) Download PDF English | Spanish

Physician Fax Form (76 KB) Download PDF English

Other Website Blocking Disable the secure member Website for yourself or a family member. (52 KB) Download PDF English Consent for Release of Protected Health Information Allow disclosure of specific information to a person or organization. (196 KB) Download PDF English

Privacy View Humana's privacy rights and forms. Individual Privacy Rights Page Prior Carrier Deductible Credit Form For new members; apply current-year expenses to Humana deductible. (28 KB) Download PDF English