12. Patient or Authorized Person's Signature Date 13. Employee's Signature Date
*Place of Service Codes
11- Doctor's Office
12- Patient's Home
20- Urgent Care
21- Inpatient Hospital
22- Outpatient Hospital
23- Emergency Room
31- Skilled Nursing Facility
32- Nursing Home
33- Other Medical/Surgical Facility
52- Psychiatric Facility
55- Residential Treatment Center
72- Rural Health Clinic
81- Independent Laboratory
99- Other Locations
11. Physician, Supplier and/or Group Name
Address, Zip Code, Telephone No. and Tax ID No.
I hereby authorize payment directly to the provider of services and I understand that I am
financially responsible for the hospital, medical, or physician charges not covered by this
Any person who knowingly and with intent to defraud any insurance company and files a
statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act, which is a crime.
If Payment Is To Be Sent Directly To ProviderRELEASE OF INFORMATION
I authorize the release of any medical information
necessary to process this claim. I understand
that, as permitted by law, to the extent of benefits
paid under this claim, the Plan acquires all rights
of recovery I may have against other parties
considered responsible for these expenses.
For use with the Humana Family
of Health Insurance and
Health Plan Companies
Health Benefits Claim Form
2. Member ID (11 characters): 3. Group Number 1. Employee/Member Name (Last) (First) (M.I.)
5. Group Name
7. Patient Birth Date:
To Be Completed By Member
10. Service Dates
CPT Code/Service Description
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.
6. Employee/Member Birth Date:
9. Patient's Relationship to Employee:
4. Employee/Member Home Address
8. Patient's Name (Last) (First) (M.I.)