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Relationships are built on trust. One of the most important
elements of trust is respect for an individual’s privacy. We
at Humana value our relationship with you, and we take
your personal privacy seriously.
This notice explains Humana’s privacy practices, our legal
responsibilities, and your rights concerning your personal
and health information. We follow the privacy practices
described in this notice and will notify you of any changes.
We reserve the right to change our privacy practices and
the terms of this notice at any time, as allowed by law.
This includes the right to make changes in our privacy
practices and the revised terms of our notice effective
for all personal and health information we maintain. This
includes information we created or received before we
made the changes. When we make a significant change
in our privacy practices, we will change this notice and
send the notice to our health plan subscribers.
What is personal and health information?
Personal and health information - from now on referred
to as “information” - includes both medical information
and individually identifiable information, like your name,
address, telephone number, or Social Security number. The
term “information” in this notice includes any personal
and health information created or received by a healthcare
provider or health plan that relates to your physical or
mental health or condition, providing healthcare to you,
or the payment for such healthcare. We protect this
information in all formats including electronic, written and
oral information.
How does Humana protect my information?
In keeping with federal and state laws and our
own policy, Humana has a responsibility to protect
the privacy of your information. We have safeguards
in place to protect your information in various
ways including:
•Limitingwhomayseeyourinformation
•Limitinghowweuseordiscloseyourinformation
•Informingyouofourlegaldutiesabout
your information
•Trainingourassociatesaboutcompanyprivacypolicies
and procedures
How does Humana use and disclose
my information?
We must use and disclose your information:
•Toyouorsomeonewhohasthelegalrighttoacton
your behalf
•TotheSecretaryoftheDepartmentofHealthand
Human Services
•Whererequiredbylaw.
We have the right to use and disclose your information:
•Toadoctor,ahospital,orotherhealthcareproviderso
you can receive medical care
•Forpaymentactivities,includingclaimspaymentfor
covered services provided to you by healthcare providers
and for health plan premium payments
•Forhealthcareoperationactivitiesincludingprocessing
yourenrollment,respondingtoyourinquiriesand
requestsforservices,coordinatingyourcare,resolving
disputes, conducting medical management, improving
quality,reviewingthecompetenceofhealthcare
professionals, and determining premiums
•Forperformingunderwritingactivities.However,wewill
not use any results of genetic testing.
•Toyourplansponsortopermitthemtoperformplan
administration functions such as eligibility, enrollment
and disenrollment activities. We may share summary
level health information about you with your plan
sponsor in certain situations such as to allow your plan
sponsor to obtain bids from other health plans. We
will not share detailed health information to your plan
sponsor unless you provide us your permission or your
plan sponsor has certified they agree to maintain the
privacy of your information.
GN14474HH 0110
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
The privacy of your personal and health information is
important. You don't need to do anything unless you
have a request or complaint.
for your personal health and financial information
Notice of
Privacy Practices
•Tocontactyouwithinformationabouthealth-related
benefits and services, appointment reminders, or about
treatment alternatives that may be of interest to you
•Toyourfamilyandfriendsifyouareunavailable
to communicate, such as in an emergency
•Toyourfamilyandfriendsoranyotherpersonyou
identify, provided the information is directly relevant
to their involvement with your health care or payment
forthatcare.Forexample,ifafamilymemberora
caregiver calls us with prior knowledge of a claim,
we may confirm whether or not the claim has been
received and paid.
•Toprovidepaymentinformationtothesubscriberfor
Internal Revenue Service substantiation
•Topublichealthagenciesifwebelievethereisaserious
health or safety threat
•Toappropriateauthoritieswhenthereareissuesabout
abuse, neglect, or domestic violence
•Inresponsetoacourtoradministrativeorder,
subpoena,discoveryrequest,orotherlawfulprocess
•Forlawenforcementpurposes,tomilitaryauthorities
andasotherwiserequiredbylaw
•Toassistindisasterreliefefforts
•Forcomplianceprogramsandhealthoversightactivities
•TofulfillHumana’sobligationsunderanyworkers’
compensation law or contract
•Toavertaseriousandimminentthreattoyourhealthor
safety or the health or safety of others
•Forresearchpurposesinlimitedcircumstances
•Forprocurement,banking,ortransplantationoforgans,
eyes, or tissue
•Toacoroner,medicalexaminer,orfuneraldirector.
Will Humana use my information for purposes
not described in this notice?
In all situations other than described in this notice,
Humanawillrequestyourwrittenpermissionbeforeusing
or disclosing your information. You may revoke your
permission at any time by notifying us in writing. We will
not use or disclose your information for any reason not
described in this notice without your permission.
What does Humana do with my information
when I am no longer a Humana member or I do
not obtain coverage through Humana?
Your information may continue to be used for purposes
described in this notice when your membership is
terminated or you do not obtain coverage through
Humana.Aftertherequiredlegalretentionperiod,we
destroy the information following strict procedures to
maintain the confidentiality.
What are my rights concerning my information?
The following are your rights with respect to
your information:
•Access–Youhavetherighttoreviewandobtaina
copy of your information that may be used to make
decisions about you, such as claims and case or medical
management records. You also may receive a summary
ofthishealthinformation.Ifyourequestcopies,we
may charge you a fee for each page, a per hour charge
for staff time to locate and copy your information,
and postage.
•AdverseUnderwritingDecision–Youhavetherightto
be provided a reason for denial or adverse underwriting
decision if Humana declines your application
for insurance.*
•AlternateCommunications–Youhavetherightto
receive confidential communications of information in
a different manner or at a different place to avoid a
life threatening situation. We will accommodate your
requestifitisreasonable.
•Amendment–Youhavetherighttorequestan
amendment of information we maintain about you if
you believe the information is wrong or incomplete.
Wemaydenyyourrequestifwedidnotcreatethe
information, we do not maintain the information, or the
information is correct and complete. If we deny your
request,wewillgiveyouawrittenexplanation
of the denial.
•Disclosure–Youhavetherighttoreceivealistingof
instances in which we or our business associates have
disclosed your information for purposes other than
treatment, payment, health plan operations, and certain
other activities. Effective April 1, 2003 or whenever
you became a Humana member, Humana began
maintaining these types of disclosures and will maintain
thisinformationforaperiodofsixyears.Ifyourequest
this list more than once in a 12-month period, we may
charge you a reasonable, cost-based fee for responding
totheseadditionalrequests.
•Notice–Youhavetherighttoreceiveawrittencopyof
thisnoticeanytimeyourequest.
•Restriction–Youhavetherighttoasktorestrict
uses or disclosures of your information. We are
notrequiredtoagreetotheserestrictions,butifwedo,
we will abide by our agreement. You also have the
Notice of
Privacy Practices (continued)
* This right applies only to our Massachusetts residents in accordance with state regulations.
right to agree to or terminate a previously
submitted restriction.
How do I exercise my rights or obtain a copy of
this notice?
All of your privacy rights can be exercised by obtaining
theapplicableprivacyrightsrequestforms.Youmay
obtain any of the forms by:
• Contactingusat1-866-861-2762atanytime
• AccessingourWebsiteatHumana.com and going to
the Privacy Practices link
• E-mailingusatprivacyoffice@humana.com
Sendcompletedrequestformto:
Humana Inc.
Privacy Office 003/10911
101 E. Main Street
Louisville,KY40202
What should I do if I believe my privacy has
been violated?
If you believe your privacy has been violated in any way,
you may file a complaint with Humana by calling us at:
1-866-861-2762anytime.
You may also submit a written complaint to the
U.S.DepartmentofHealthandHumanServices,
OfficeofCivilRights(OCR).Wewillgiveyouthe
appropriateOCRregionaladdressonrequest.You
also have the option to e-mail your complaint to
OCRComplaint@hhs.gov.Wesupportyourrighttoprotect
the privacy of your personal and health information. We
will not retaliate in any way if you elect to file a complaint
withusorwiththeU.S.DepartmentofHealthand
Human Services.
PRIVACY NOTICE CONCERNING
FINANCIAL INFORMATION
Humana and our affiliates understand that the privacy
of your personal information is important to you. We
take your privacy seriously and your trust in our ability
to protect your private information is very important
to us. This notice describes our policy regarding the
confidentiality and disclosure of personal
financial information.
How does Humana collect information
about me?
We collect information about you and your family when
you complete applications and forms. We also collect
information from your dealings with us, our affiliates, or
others.Forexample,wemayreceiveinformationabout
you from participants in the healthcare system, such
as your doctor or hospital, as well as from employers
or plan administrators, credit bureaus, and the Medical
Information Bureau.
What information does Humana receive
about me?
The information we receive may include such items as
your name, address, telephone number, date of birth,
Social Security number, premium payment history,
and your activity on our Website. This also includes
information regarding your medical benefit plan, your
health benefits, and health risk assessments.
Where will Humana disclose my information?
We may share your information with affiliated companies
and non-affiliated third parties, as permitted by law. We
may also provide your information to other financial
institutions with which we have joint marketing
agreements in order to provide you with offers for
products and services you may find of value or which are
health-related.
What can I prevent with an opt-out disclosure?
You can prevent the disclosures to non-affiliated
third parties that provide products and services not
offered by Humana or where the non-affiliated company
providesservicesrelatedtoyourplanbyrequestingto
opt-outofsuchdisclosures.Youropt-outrequestwill
apply to all members or individuals covered under your
Humana identification number or member account.
Youropt-outrequestwillcontinuetoapplyuntilyou
revokeyourrequestorterminateyourmembership.
How do I request an opt-out?
At any time you can tell Humana not to share any of
your personal information with affiliated companies that
provide offers of non-Humana products or services. If
you wish to exercise your opt-out option, or to revoke
apreviousoptoutrequest,youneedtoprovidethe
followinginformationtoprocessyourrequest:yourname,
date of birth, and your Humana member identification
Notice of
Privacy Practices (continued)
GN14474HH 0110
number.Youcanuseanyofthemethodsbelowtorequest
or revoke your opt-out:
• Callusat1-866-861-2762
• E-mailusatprivacyoffice@humana.com.
• Sendyouropt-outrequesttousinwriting:
Humana Inc.
Privacy Office 003/10911
101 E. Main Street
Louisville,KY40202
Humana follows all federal and state laws, rules,
and regulations addressing the protection of personal and
health information. In situations when federal and state
laws, rules, and regulations conflict, Humana follows the
law, rule, or regulation which provides greater protection.
The following affiliates and subsidiaries also adhere to
Humana’s privacy policies and procedures:
AmericanDentalPlanofNorthCarolina,Inc.
AmericanDentalProvidersofArkansas,Inc.
CarePlusHealthPlans,Inc.
CaritenHealthPlan,Inc.
CaritenInsuranceCompany
CompBenefitsCompany
CompBenefitsDental,Inc.
CompBenefitsInsuranceCompany
CompBenefitsofAlabama,Inc.
CompBenefitsofGeorgia,Inc.
CorpHealth,Inc.dbaLifeSynch
CorpHealthProviderLink,Inc.
DentiCare,Inc.
Emphesys, Inc.
EmphesysInsuranceCompany
HumanaDentalInsuranceCompany
HumanaAdvantageCarePlan,Inc.fnaMetcareHealth
Plans, Inc.
HumanaBenefitPlanofIllinois,Inc.fnaOSFHealth
Plans, Inc.
Humana Employers Health Plan of Georgia, Inc.
HumanaHealthBenefitPlanofLouisiana,Inc.
HumanaHealthInsuranceCompanyofFlorida,Inc.
HumanaHealthPlanofCalifornia,Inc.
Humana Health Plan of Ohio, Inc.
Humana Health Plan of Texas, Inc.
Humana Health Plan, Inc.
Humana Health Plans of Puerto Rico, Inc.
HumanaInsuranceCompany
HumanaInsuranceCompanyofKentucky
HumanaInsuranceCompanyofNewYork
Humana Insurance of Puerto Rico, Inc.
Humana MarketPOINT, Inc.*
Humana MarketPOINT of Puerto Rico, Inc.*
Humana Medical Plan, Inc.
HumanaMedicalPlanofUtah,Inc.
Humana Pharmacy, Inc.
Humana Wisconsin Health Organization
 InsuranceCorporation
KanawhaInsuranceCompany*
ManagedCareIndemnity,Inc.
Preferred Health Partnership, Inc.*
Preferred Health Partnership of Tennessee, Inc.
TheDentalConcern,Inc.
TheDentalConcern,Ltd.
* These affiliates and subsidiaries are only covered by the Privacy Notice
ConcerningFinancialInformationsection.
Notice of
Privacy Practices (continued)
AR-72000 1/2008 1 Reorder# AR-51340-HD 3/2008
Humana Employee Enrollment Form - Dental, Life, Vision ARKANSAS
The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana”.
Life and Vision plans insured or administered by Humana Insurance Company. Dental plans insured or administered by HumanaDental Insurance Company
or Humana Insurance Company. CompBenefits Vision plan insured or administered by CompBenefits Insurance Company.
Please print clearly and fill in each applicable circle. Proposed effective date: _ _ / _ _ / _ _ _ _
Company name Company city State
Enrollment Information
AR-72000-EI 1/2008
Relationship
Last name, First name MI
Height
(ft / in)
Weight
(lbs.) Gender
Full-time
student?
Date of birth
Disabled?
If yes, indicate reason.
Employee
/
m F
m M
N/A _ _ / _ _ / _ _ _ _
m N
m Y
Reason:
Spouse
/
m F
m M
N/A _ _ / _ _ / _ _ _ _
m N
m Y
Reason:
Child
/
m F
m M
m N
m Y
_ _ / _ _ / _ _ _ _
m N
m Y
Reason:
Child
/
m F
m M
m N
m Y
_ _ / _ _ / _ _ _ _
m N
m Y
Reason:
Child
/
m F
m M
m N
m Y
_ _ / _ _ / _ _ _ _
m N
m Y
Reason:
Other (specify):
/
m F
m M
m N
m Y
_ _ / _ _ / _ _ _ _
m N
m Y
Reason:
EMPLOYEE INFORMATION:
HOURS WORKED PER WEEK:
m RETIREE
DATE OF FULL-TIME HIRE: _ _ / _ _ / _ _ _ _
SSN # Street address APT / Suite / Box
City State Zip code Phone # ( )
Language: m English m Spanish
Email address
Dental
Group #:
Benefit #: Class/Div: AR-72000-HD 1/2008
Coverage type: m Employee only m Employee and spouse m Employee and child(ren)
m Family m NO COVERAGE (complete waiver)
Plan name
Prior dental coverage during the past 12 months (individual or other group coverage)? m N m Y
Prior dental insurance carrier name Prior coverage type:
m Employee only
m Employee and spouse
m Employee and child(ren)
m Family
Effective date
_ _ / _ _ / _ _ _ _
Policy #
Prior orthodontia coverage in the past 12
months? m N m Y
Term date
_ _ / _ _ / _ _ _ _
Prior carrier phone # ( )
Basic Life
Group #:
Benefit #: Class/Div: AR-72000-BL 1/2008
Primary beneciary name (Last, First MI) Secondary beneciary name (Last, First MI)
Class (employer will provide you
with this information if needed)
Annual salary (if applicable)
$
Basic dependent life?
m N m Y
If no, complete waiver section.
Voluntary Life
Group #: Benefit #: Class/Div: AR-72000-VL 1/2008
Voluntary employee life
coverage? m N m Y
Amount (min $15,000)
$
Primary beneciary name (Last, First MI) Secondary beneciary name (Last, First MI)
Voluntary spouse life
coverage? m N m Y
Amount (min. $5,000)
$
Voluntary child(ren) life coverage?
m N m Y
Annual employee salary (if applicable)
$
Vision
Group #: Benefit #: Class/Div: AR-72000-VS 1/2008
Coverage type: m Employee only m Employee and spouse m Employee and child(ren)
m Family m NO COVERAGE (complete waiver)
Plan name
Visit us at www.humana.com or www.humanadental.com
Print Form
AR-72000 1/2008 2 Reorder# AR-51340-HD 3/2008
First name:Last name:
Waiver (refusal of coverage)
AR-72000-WV 1/2008
I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer. I proclaim that I
was not pressured or forced by my employer, the writing agent, or Humana into waiving (declining) coverage. If I have waived any coverage offered to me or my
dependents, my signature is evidence of this action.
I hereby waive coverage for (check all that apply):
Dental for: m Myself m My spouse m My dependent child(ren)
Basic Life for: m Myself m My spouse m My dependent child(ren)
Vision for: m Myself m My spouse m My dependent child(ren)
I decline to apply for group coverage because of:
m Spousal coverage
m Medicare supplement
m Individual coverage
m Coverage under another carrier’s plan provided by my employer
m Other:
Agreement
AR-72000-AA 1/2008
True and complete acknowledgement
I understand, agree and represent:
• I have read this document or it has been read to me and answers provided are true and complete to the best of my knowledge and belief.
• Neither my employer nor the agent can waive any question, determine coverage or insurability, alter any contract or waive any of Humana’s other rights
and requirements.
• If this application for coverage is accepted, coverage will be effective on the date specied by Humana on the certicate of coverage/certicate of insurance. If I
have a new dependent as a result of a qualifying event, I may in the future be able to enroll myself or my dependents provided I request enrollment with in 31
days after the qualifying event.
• In the event that I should decide to apply for coverage hereafter, that subsequent application shall be subject to the applicable terms and conditions of the master
group contract(s) or plan provisions which may require additional limitations and waiting periods.
• I may be required to furnish, at my own expense, evidence of health status satisfactory to Humana.
• If I am declining coverage for myself or my dependents (including my spouse) because of other coverage, I may in the future be able to enroll myself or my
dependents provided that I request enrollment within 31 days after my other coverage ends.
• Humana reserves the right to delay medical coverage and/or deny life or dental coverage with any future application for coverage.
• If any deductions are required for this coverage, I authorize those deductions from my earnings. If selecting the Health Savings Account (HSA), I authorize
Humana or its banking partners to provide my account number to my employer for the purposes of depositing any contributions.
• Any misrepresentation contained herein relied on by Humana may be used to reduce or deny a claims or void the contract within the contestable period if such
misrepresentation materially affected the acceptance of the risk.
• Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet knowingly presents information in an application of insurance is
guilty of a crime and may be subject to nes and connement in prison.
Authorization
My dependents and I authorize any third party to have information regarding myself and my dependents. This includes any medical or non-medical information and
to share any and all such information with Humana, its reinsurer or its legal representatives, and its afliates.
My dependents and I understand and agree:
• The information obtained by use of this authorization may be used by Humana to make claims determinations, determine eligibility for coverage, eligibility for
benets under an existing policy and plan administration.
• Any information obtained will not be released by Humana to any person or organization except to reinsuring companies, the Medical Information Bureau, Inc. or
other persons or organizations performing health care operations or business or legal services in connection with an application, claim or as may be otherwise
lawfully required, or as I (we) may further authorize. Once personal and health (including medical, dental and pharmacy) information is disclosed pursuant to this
authorization, the recipient may redisclose it and the information may not be protected by federal and state privacy requirements.
• A photographic copy of this authorization shall be as valid as the original.
• This authorization shall be valid for two years from the date shown below and I have the right to revoke this authorization at any time by writing to Humana’s
Privacy Ofce.
This document, together with any supplements, will form part of any contract and be the basis for any certicate of coverage/certicate of insurance issued.
Signature - please sign below if enrolling or waiving group coverage.
AR-72000-SA 1/2008
If you decide not to sign this authorization, Humana cannot complete your plan enrollment or determine your premium rate due to the
inability to obtain the necessary information.
Employee or legal representative signature: _____________________________________________ Date: ____________________
Name and relationship of legal representative: _______________________________________________________________________
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Completed 21 July 2020

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