Get Humana Pharmacy Contract Request Form

Completing the Humana Pharmacy Contract Request Form is an essential step for pharmacies seeking to join the Humana network. This guide will walk you through each section of the form, ensuring that you provide all required information accurately when filling it out online.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the requestor's name and the date the form is being requested. This information is crucial for record-keeping and tracking your request efficiently.
3. Indicate the pharmacy's location by checking the appropriate box for either Michigan Pharmacy Locations or Out-of-Michigan Pharmacy Locations. If the latter is checked, follow the instructions to contact Express Scripts.
4. Select whether this is a new pharmacy application or a change of ownership for an existing pharmacy by checking the corresponding box.
5. Answer the question regarding ownership of stock in other pharmacies. Indicate 'Yes' or 'No' based on your situation.
6. Fill in the NCPDP number if known, along with the pharmacy name and the attention of the contact person.
7. Indicate whether all pharmacies are located within the state of Michigan by checking 'Yes' or 'No.' If 'Yes,' also specify the number of pharmacies.
8. Provide the anticipated opening or effective date for the pharmacy.
9. Complete the NPI number if known, and provide the pharmacy phone number along with the first and last name of the contact person.
10. Fill in the pharmacy fax number, address (street, city, state, and zip code), and contact phone number.
11. List all owners of the pharmacy, including any shareholders, silent partners, or other relevant individuals.
12. Review all provided information for accuracy. Once confirmed, save your changes, and download, print, or share the form as needed.

Complete your Humana Pharmacy Contract Request Form online and ensure a smooth contracting process.