Forms

Eligibility Forms for All Plans:

• Certification of Disabled Dependent Child
• Legal Guardianship Certification
• Release of Information Authorization

Consumer Driven Health Plan Forms:

• Expedited Appeal Review
• Express Scripts RX Reimbursement Claim Form
• Express Scripts RX Mail Order Delivery Form 
• External Appeal Review Request Level 3
• HealthSCOPE Medical Claim Form
• Hometown Health Utilization and Case Management Prior Authorization Form
• HRA Claim Form
• HSA Beneficiary/Spousal Consent Form
• HSA Claim Form
• Internal Claim Appeal Request Level 2
• Obesity Care Management Initial Evaluation Form
• Obesity Care Management Meal Therapy Reimbursement Form
• Diabetes Care Management Form
• Physician Certification of Experimental/Investigational Denials Form
• Travel Pre-Authorization for Organ/Tissue Transplant or Bariatric Surgery
• Travel Reimbursement Form for Organ/Tissue Transplant/Bariatric Surgery

Health Plan of Nevada (HPN) Forms:

• Non-Plan Provider Claim Form
• Optum Pharmacy Mail Order Form
• Optum Pharmacy Reimbursement Form

Premier Plan (EPO) Forms:

• Expedited Appeal Review
• Express Scripts RX Reimbursement Claim Form
• Express Scripts RX Mail Order Delivery Form
• External Appeal Review Request Level 3
• HealthSCOPE Medical Claim Form
• Hometown Health Utilization and Case Management Prior Authorization Form
• Internal Claim Appeal Request Level 2
• Obesity Care Management Initial Evaluation Form
• Obesity Care Management Meal Therapy Reimbursement Form
• Physician Certification of Experimental/Investigational Denials Form
• Travel Pre-Authorization for Organ/Tissue Transplant or Bariatric Surgery
• Travel Reimbursement Form for Organ/Tissue Transplant/Bariatric Surgery

Dental Plan Forms:

• Dental Claim Form

Public Records Request Forms:

• Public Records Request
• Public Records Request Form
• Public Records Request Initial Receipt Response
• Release of Information Authorization
• Fee Schedule for Public Records Requests

Standard Insurance Forms:

• Beneficiary and Designation Change Form
• Group Life Conversion Form
• Group Life Portability Form
• Life Insurance Claim Form
• Voluntary Life Enrollment Form

Hometown Health (HTH) Forms:

• Costco Prescription Mail Order Form
• Hometown Rx Prescription Mail Order Form
• Medical Claim Form

Retirees that are not on the Medicare Exchange and participate in the PPO, EPO or HMO will find the forms they need under the Pre-Medicare Retirees section.

Eligibility Forms for All Plans:

• Release of Information Authorization

PPO Dental Plan Forms:

• PPO Dental Claim Form

Public Records Request Forms:

• Public Records Request
• Public Records Request Form
• Public Records Request Initial Receipt Response
• Release of Information Authorization
• Fee Schedule for Public Records Requests

Standard Insurance Forms:

• Beneficiary and Designation Change Form
• Group Life Conversion Form
• Group Life Portability Form
• Life Insurance Claim Form
• Voluntary Life Enrollment Form