Forms

We want you to easily find the forms you need. Listed below are forms you may need as a Humana – CareSource® member. Just click on the name to open and print the form you need.

Look for instructions on the form. The instructions will tell you where you need to return each form, who to contact if you have questions, and any next steps to take.

NavigateAppeal Request Form – Use this form when you do not agree with a decision or action made by Humana – CareSource in regard to your medical care.

You have the right to appeal when:

  • Humana – CareSource denies a service.
  • Humana – CareSource gives partial approval to cover a service.
  • Humana – CareSource denies payment of a service.

To learn more, visit the File an Appeal page.

NavigateFraud, Waste & Abuse Reporting Form – Use this form If you think a health partner or a Humana – CareSource member is committing fraud, waste or abuse. To find out more, visit the Fraud, Waste, & Abuse page.

NavigateGrievance Request Form – Use this form when you are not happy with something about the way your Humana – CareSource plan works.

For example, you may be unhappy because:

  • You cannot get a timely appointment with a provider.
  • You think the provider’s office staff did not treat you fairly.
  • You are not satisfied with the quality of care you received.

Need more information? Visit the File a Grievance page.

NavigateKLIP Provider Change Form – Use this form if you are enrolled in the KY Lock-In Program (KLIP) and want to change your provider. KLIP members may request a change of any provider only one time during enrollment in the Lock-In Program.

Member Request for a Non-Formulary Medication – Use this form when you want to request a drug that is not listed on the Preferred Drug List (PDL)

HIPAA Authorization Form – Use this online form to grant Humana – CareSource permission to speak to another individual on your or your child’s behalf, and/or release health information to someone you name. Or download this hard copy version and mail or fax the completed form to Member Services. Please allow up to 30 days to process the hard copy form. 

Tell Us Form – Use this form when you would like to send us a question or request online.