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:

This form grants Humana permission to release or disclose a member's protected health information to other individuals named on the form. This form was last updated in April 2008.

(196 KB) Download PDF
English | Spanish

Revocation of Consent for Release of Protected Health Information

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. This form was last updated in April 2008.

(196 KB) Download PDF
English | 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. This form was last updated on April 18, 2008.

(108 KB) Download PDF
English | Spanish

Request Amendment to your Protected Health Information

This form requests a correction to Humana-created protected health information that a member feels is inaccurate or incomplete. This form was last updated in April 2008.

(108 KB) Download PDF
English | Spanish

Request to Access Protected Health Information

This form requests an inspection or copy of Humana-maintained protected health information about a member. This form was last updated on April 18, 2008.

(208 KB) Download PDF
English | Spanish

This form withdraws a previously requested restriction of a member's protected health information. The form was last updated in April 2008.

(104 KB) Download PDF
English | 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 different address. This form was last updated in April 2008.

(108 KB) Download PDF
English | Spanish

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 in April 2008.

(92 KB) Download PDF
English | Spanish