Edit, Download, and Sign the Humana Pharmacy Contract Request Form
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How do I fill this out?
To fill out this form, gather all necessary pharmacy information before you begin. Complete each section with accurate details about your pharmacy, services, and ownership. Make sure to review the form thoroughly before submission to ensure all information is correct.
How to fill out the Humana Pharmacy Contract Request Form?
1
Gather necessary pharmacy information.
2
Complete each section with accurate details.
3
Provide information about services offered.
4
Review the form thoroughly.
5
Ensure all information is correct before submission.
Who needs the Humana Pharmacy Contract Request Form?
1
Independent pharmacy owners looking to contract with Humana.
2
Pharmacy chains expanding their network with Humana.
3
Pharmacies offering specialty services seeking Humana contracts.
4
Long-term care pharmacies requiring Humana approval.
5
New pharmacy owners needing to update their information with Humana.
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1
Upload the form to PrintFriendly.
2
Use the PDF editor to fill out required fields.
3
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5
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What are the instructions for submitting this form?
Submit the completed form via email at HumanaContracts@humana.com, by fax to (123) 456-7890, or mail to Humana Pharmacy Contracting, 123 Main St, Louisville, KY 40202. Ensure all sections are filled out completely and accurately. Attach any additional required documents as specified in the form instructions. Double-check all provided information to avoid delays in processing.
What are the important dates for this form in 2024 and 2025?
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What is the purpose of this form?
The Humana Pharmacy Contract Request Form serves as a means for pharmacies to initiate a contract with Humana's network. By completing this form, pharmacies ensure that they meet Humana's requirements and standards for service delivery. This form also helps Humana maintain accurate and up-to-date records of participating pharmacies, ensuring seamless operations and compliance.
Tell me about this form and its components and fields line-by-line.
- 1. Pharmacy NCPDP: The unique identifier assigned to the pharmacy.
- 2. Pharmacy DBA name: The Doing Business As name of the pharmacy.
- 3. Pharmacy physical address: The physical location of the pharmacy.
- 4. City: The city where the pharmacy is located.
- 5. Pharmacy phone number: The contact phone number for the pharmacy.
- 6. Pharmacy contracting contact name: The name of the contact person for pharmacy contracting.
- 7. Pharmacy mailing address: The mailing address for the pharmacy.
- 8. Tax Identification Number (TIN): The tax identification number for the pharmacy.
- 9. Pharmacy NPI: The National Provider Identifier for the pharmacy.
- 10. Pharmacy legal name: The legal name of the pharmacy.
- 11. State: The state where the pharmacy is located.
- 12. ZIP code: The postal code for the pharmacy.
- 13. Pharmacy fax number: The fax number for the pharmacy.
- 14. Pharmacy owner: The name of the owner of the pharmacy.
- 15. County: The county where the pharmacy is located.
- 16. Medicaid ID: The Medicaid identifier for the pharmacy.
- 17. Email address: The email address where contract notifications will be sent.
What happens if I fail to submit this form?
Failure to submit this form may lead to delays in contracting with Humana. Missing this submission can also result in non-compliance with Humana's network requirements.
- Contracting Delays: Delays in establishing or renewing a contract with Humana.
- Non-Compliance: Non-compliance with Humana's network requirements.
How do I know when to use this form?
- 1. New Contract Request: For pharmacies seeking to initiate a new contract with Humana.
- 2. Update Information: For pharmacies updating their address, phone number, or other details.
- 3. Ownership Change: When there is a change in the ownership of the pharmacy.
- 4. Service Update: For pharmacies notifying Humana of changes in services offered.
- 5. Additional Locations: For pharmacies adding or updating information for multiple locations.
Frequently Asked Questions
How do I fill out the Humana Pharmacy Contract Request Form?
Simply use our PDF editor to enter your pharmacy's details and ensure all information is accurate before submission.
Can I edit the form after saving?
Yes, you can edit the form anytime before submission using our PDF editor.
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Use our signature tool to type, draw, or upload an image of your signature.
Is it possible to share the completed form?
Yes, you can share the form via email or generate a shareable link directly on PrintFriendly.
What types of pharmacies need to fill out this form?
Independent pharmacies, pharmacy chains, specialty pharmacies, long-term care pharmacies, and new pharmacy owners may need to fill out this form.
What information should I gather before filling out the form?
Gather all necessary pharmacy information, including services offered and ownership details.
How can I ensure my form is correctly filled before submission?
Review the form thoroughly to confirm all information is correct and complete.
Can the form be saved for later completion?
Yes, you can save the form and complete it later using our PDF editor.
What if I need to attach additional information?
You can attach additional information by uploading relevant documents on PrintFriendly.
How do I submit the completed form?
Follow the instructions provided for submission, which may include email, fax, or online submission.
