Form Il-71096 Nf - Humanaone Dental - Vision Paper Application Checklist printable pdf download

HumanaOne Dental & Vision Paper Application Checklist

TO ENSURE PROCESSING PLEASE USE THIS CHECKLIST

Did you ﬁll out the application completely?

Include your effective date. The effective date should be “mm/dd/yyyy”. The requested effective date should be in the future.

Please note the effective date rules below:

For Dental C550 and HI215 products: if an application is received prior to the 15th of the month, the effective date is the 1st of the following

month. If the application is received after the 15th of the month, the effective date will be the 1st of the subsequent month.

EXAMPLE: An application received on May 14th will have an effective date of June 1st. An application received on May 18th will have an

effective date of July 1st.

For all other products, applications received between the 1st and the last day of the month will be effective the ﬁrst of the following month.

EXAMPLE: An application received on May 21st will have an effective date of June 1st.

Coverage Options: Please check the box of the coverage option(s) that you are interested in and include the product names.

Primary Insured Information: The following ﬁelds are required for the primary applicant: Full Name, Date of Birth, Address,

City, State, ZIP code, Social Security Number, and Dentist Facility ID number (for Dental C550 and HI215 applicants only. Please visit

to ﬁnd a dentist).

Family Information: The following ﬁelds are required for a spouse and/or dependents: Full Name, Date of Birth and Social Security Number.

Agent/ Producer Information: The following ﬁelds are required from the agent (if applicable): Name, Humana Agent #, License #,

and Signature.

Agreement and Signature: Please read the agreement and sign and date all applicable lines.

Second page: Payment & Billing Authorization

Please indicate whether you will be paying monthly or annually.

Please check the plan that you are purchasing in the chart and write in the total ﬁrst payment amount equal to the enrollment fee(s) and

the monthly/ annual payment total indicated in the chart.

If you are enrolling in more than one plan, please add the payment totals from the chart together for each plan and include enrollment

fees for both plans.

PLEASE NOTE: Your ﬁrst payment will be taken immediately upon receipt of the application, so please ensure that the payment

method provided has funds available/covers this transaction and is accurate and up-to-date.

Payor Information: Only ﬁll out this section of the billing name or address is different than the information provided on the ﬁrst page

for the primary insured. The payor will also need to sign the Payor Signature line at the bottom of the application.

Payment Options: Please check whether you will be paying via credit card, automatic bank withdrawal, or check/ money order.

Please include all requested information and check the payment authorization box under your payment method.

If you are paying through automatic bank withdrawal, make sure to include your account information and a blank voided check

along with the application.

If paying with a credit card, please check your credit card’s expiration date. This card will be charged for future payments,

so please alert us with any changes.

All signature areas are signed and dated. Please make sure you have read and agreed to the one year contract language.

Have you reviewed our provider network?

To see providers in our network for all plans, please visit and enter your zip code and plan name.

Would you like to fax your application?

Only credit card and bank withdrawal applications may be faxed. Please keep the original application and submit a faxed copy to the

Humana One Dental & Vision Paper Application team at 502-508-6500. If you are faxing an automatic bank withdrawal application,

please fax a copy of a blank voided check.

Are you making changes to an existing plan or reinstating a previous plan?

For changes to existing plans or for reinstatements, please call: 1-866-537-0232.

GCA0CS2HH 0312

Form Il-71096 Nf - Humanaone Dental - Vision Paper Application Checklist

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