Humana Online Application

Step 1: Pricing Information

Humana Online Application

Step 1: Pricing Information

Date Of Birth

Gender

Zip Code

County

State

Plan

Requested Start Date

Step 3: Address Information

Home Street Address

Apt, Suite (optional)

City

Zip Code

County

State

Check box if mailing address is different than home address

Step 5: Other Information

What is your Veteran Status?

I am completing the application on my own

Yes

Please Note: Power of Attorney must cover the ability to make healthcare decisions and is usually referred to as a Durable Power of Attorney for Healthcare or Healthcare Power of Attorney.

POA Full Name

POA First Name

POA Last Name

POA Address

POA Street Address

POA Apt, Suite (optional)

POA City

POA State

POA Zip Code

POA Phone Number

POA Relationship to Applicant

Materials On-Line

Choosing our online option is a great way to stay organized. You'll be asked on your Enrollment Application how you want to receive the following plan materials. If you choose digital, we'll send you an email when your documents are available so that you can view them online in your secure, MyHumana account. Registering for your MyHumana account is easy. Visit Humana.com to get started.

I choose to receive the following documents on-line:

Verification of Enrollment
Plan Coverage Package (Evidence of Coverage, Summary of Benefits, Plan Stars Rating, and Value-Added Services)
Renewal Information (Annual Notice of Change/and Evidence of Coverage and Drug List for next plan year)
Plan messages and notifications

Yes - I wish to go Digital

No thanks

Information provided may be used to contact you via mail, phone or email if additional information is needed to complete this application.

Need assistance?

Call us at

Returning Users

If you already have an account then please click here to sign in.

Humana Online Application

Step 1: Pricing Information