For use with the Humana Family
of Health Insurance and
Health Plan Companies
Health Benefits Claim Form
To Be Completed By Member
1. Complete ALL information requested below.
2. Use separate form for each family member and for each accident or illness.
3. Enclose ORIGINAL itemized bills. Please keep a copy for your records. Cancelled checks ARE NOT acceptable.
4. ASSIGNMENT: If you wish benefits to be paid directly to the physician or provider of service, sign the Direct Payment block
below. NOTE: Benefits for hospital confinement will be paid directly to the hospital.
5. Mail completed form to the address on the back of your insurance card.
1. Employee/Member Name (Last)
2. Member ID (11 characters):
3. Group Number
5. Group Name
4. Employee/Member Home Address
6. Employee/Member Birth Date:
8. Patient's Name (Last)
10. Service Dates
9. Patient's Relationship to Employee:
CPT Code/Service Descriptio