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PHI form - English V.2 - Rogers Benefit Group 2026

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The document is a consent form for the release of protected health information (PHI) related to Humana's CoverageFirst PPO plan. It allows members to authorize the disclosure of their health information to designated individuals or organizations for assistance with their Humana plan. The form includes sections for member details, the type of information to be released, and recipient information. It also outlines the member's rights regarding revocation of consent and expiration of authorization.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information in the 'Member information' section. Fill in your name, date of birth, address, member ID, and phone number.
Select the type of protected health information you wish to authorize for release by checking one of the provided boxes.
If applicable, specify any particular condition or injury for which you are authorizing the release of information in the designated area.
Provide details about the individual or organization that will receive this information, including their name, address, email, and relationship to you.
Sign and date the form at the bottom. If you are a legal representative, ensure to attach necessary documentation as required by law.
Once completed, fax your form to 1-800-633-8188 or mail it to Humana Insurance Company at the specified address.

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2012	4.8 Satisfied (218 Votes)
2010	4.1 Satisfied (65 Votes)

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