Forms
Here you will find useful forms such as claim forms and appeal forms.
Eligibility Forms for All Plans:
- Insurance Marketplace Coverage Options for Eligible New Hires
- Insurance Marketplace Coverage Options for Ineligible New Hires
- Certification of Disabled Dependent Child
- Legal Guardianship Certification
- Release of Information Authorization
Consumer Driven Health Plan Forms:
- Diabetes Care Management Form
- 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
- HRA Claim Form
- HSA Beneficiary/Spousal Consent Form
- HSA Claim Form
- HSA Contribution 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
Flexible Spending Account Forms:
Health Plan of Nevada (HPN) Forms:
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
- 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:
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:
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:
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:
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:
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:
PPO Dental Plan Forms:
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: