Humana pain management form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Provider Information section. Enter the Fax Date, Provider Name, and contact details including Telephone Number and Fax Number. Ensure all fields are completed accurately.
3. Next, move to the Patient Information section. Input the patient's First Name, Last Name, HUMANA Member ID Number, Date of Birth, and Diagnosis Code in ICD-10 format.
4. In the Request Information section, check all applicable boxes for requested procedures and spinal regions. Be sure to indicate if this is the first epidural steroid or facet injection for the patient.
5. Finally, provide any additional details such as CPT Codes and Anticipated Date of Service(s). Review all entries for accuracy before submitting.

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