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Get Humana GNHHA5RHH 2014

Make checks payable to RightSource. Please do not send cash. There is a $25 charge for all returned checks. To pay by Credit Card, please complete the following: Credit / Debit Card # Cardholder First Name Expiration Date M M Y Y Cardholder Last Name Cardholder Signature Note: A monthly allowance amount is only available if your plan offers the over-thecounter (OTC) services as a benefit. Call RightSource at 1-855-211-8370 (TTY: 711) to confirm your eligibility, Monday – Friday, 8 a.m. to .

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