Other Humana Sites Help Español Shop for Plans Member Resources Sign in Home Member guidance Documents and forms 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 Health benefits claim form , PDF opens new window International health benefits claim form - English , PDF opens new window International health benefits claim form - Spanish , PDF opens new window Medicare Advantage and Prescription Drug Plan Disenrollment Instructions and Form Medicare advantage and prescription drug plan disenrollment form - English , PDF opens new window Medicare advantage and prescription drug plan disenrollment form - Spanish , 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 drug coverage determination There may be times when it is necessary to get approval from Humana before getting a prescription filled. This is called “prior authorization” or Part D coverage determination. Online request for Part D drug prior authorization , opens new window Downloadable request forms for Part D prior authorization Part D drug prior authorization form – English , PDF opens new window Part D drug prior authorization form - Spanish , PDF opens new window Learn more about the Part D drug prior authorization process Grievance, appeal and coverage redetermination If you have a complaint related to your Humana Part C/Medicare Advantage plan, Part D drug coverage or any aspect of a member's care, we want to hear about it and see how we can help. You can use this form to: File an appeal for a denied medical service, a medical device or a denied prescription medication. Submit a grievance about your complaint and tell us how you are dissatisfied with your experience. Please provide complete information, so we can get your issue to the associate who can help you best. Online request for appeals, complaint and grievances , opens new window Downloadable request forms for grievance, appeal and coverage redetermination Appeal, complaint, or grievance form - English , PDF opens new window Appeal, complaint, or grievance form - Spanish , PDF opens new window Learn more about the Medicare drug (Part D) coverage redetermination process Learn more about the Medicare Advantage (Part C) reconsideration process Appointment of representative form for appeals and grievances If you are filing an appeal or grievance on behalf of a member, you need an Appointment of Representative (AOR) form or other appropriate legal documentation on file with Humana so that you are authorized to work with Humana on his or her behalf. Appointment of representative form - English , PDF opens new window Appointment of representative form - Spanish , PDF opens new window You also can get the Appointment of Representative form on the Centers for Medicare & Medicaid Services website , opens new window . Report an injury or get information about an injury investigation Use the Injury Report and File Status Request , PDF opens new window to: Report accidents Confirm if Humana provided benefits for an accident-related injury or illness Request final payment information needed to settle claims made against other insurance carriers and individuals Once you have completed the request, please email a saved copy to SubrogationReferrals@Humana.com, or mail to: Humana Subrogation and Other payer Liability 004/48110 P.O. Box 2257 Louisville, KY 40201-2257 If you have additional questions or need to supply additional information, please contact us. Notice of nondiscrimination Please visit our accessibility page for information on filing a discrimination complaint Multi-language translator service Multi-language interpreter services contact information Member blocking request Disable access to your secure member website for yourself or a family member Website blocking request , 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 Back to top Medicare Dental Vision Medicaid Pharmacy Member Resources Find a Doctor Sign in to MyHumana Sign in to Go365.com Employers Agents & Brokers Providers Caregivers About Humana Contact Us Careers Investor Relations Corporate Responsibility © Humana 2021 Legal Privacy Policies Internet Privacy Statement Site Map Disclaimers & Licensure Fraud, Waste & Abuse Accessibility System Requirements This material is provided for informational use only and should not be construed as medical advice or used in place of consulting a licensed medical professional. You should consult your doctor to determine what is right for you. Humana is a Medicare Advantage HMO, PPO and PFFS organization and a stand-alone prescription drug plan with a Medicare contract. Enrollment in any Humana plan depends on contract renewal. Y0040_GHHHG57HH_v3 Approved Last Updated: 10/01/2015