Individual Privacy Rights

Individual Rights Forms

The following is a brief description of the various individual rights and the appropriate form to invoke one of these rights:

Consent for Release of Personal and Health Information

This form grants Humana permission to release or disclose a member's personal and health information to other individuals named on the form. For return address information, call a Customer Care representative using the toll-free number on your Humana member ID card. This form was last updated on July 13, 2005.

(PDF 104KB) - Download PDF

Revocation of Consent for Release of Personal and Health Information

This form terminates previously granted permission for Humana to release or disclose a member's personal and health information to other individuals named on the form. For return address information, call a Customer Care representative using the toll-free number on your Humana member ID card. This form was last updated on July 13, 2005.

(PDF 96KB) - Download PDF

Request for Accounting of Disclosures

This form requests a list of disclosures Humana made of a member's personal and health information. Disclosures made for payment and health plan operations are excluded from this process. This form was last updated on July 13, 2005.

(PDF 112KB) - Download PDF

Request Amendment to your Protected Health Information

This form requests a correction to Humana-created personal and health information that a member feels is inaccurate or incomplete. This form was last updated on July 13, 2005.

(PDF 104KB) - Download PDF

Request to Access Personal and Health Information

This form requests an inspection or copy of Humana-maintained personal and health information about a member. This form was last updated on March 31, 2005.

(PDF 108KB) - Download PDF

Request for Restriction of Personal and Health Information

This form requests limitation or restriction of disclosures of a member's personal and health information to others such as a family member, friend, spouse, doctor, or any other party. This form was last updated on July 13, 2005.

(PDF 104KB) - Download PDF

Request for Termination of Restriction

This form withdraws a previously requested restriction of a member's personal and health information. The form was last updated on July 13, 2005.

(PDF 96KB) - Download PDF

Request for Alternate Communications

This form requests that Humana communicate with a member about personal and health information in a different way during life-threatening situations. Examples of alternate means could include telephone, mail, e-mail, or different address. This form was last updated on July 13, 2005.

(PDF 102KB) - Download PDF

HIPAA Privacy Complaint Form

This form documents an issue or concern if a member believes his or her privacy rights may have been violated. This form was last updated on July 13, 2005.

(PDF 100KB) - Download PDF