Forms
Here you will find useful forms such as claim forms and appeal forms.
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
- HealthSCOPE Medical Claim Form
- Hometown Health Prior Authorization Referral 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
- 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
Eligibility Forms for All Plans:
- Certification of Disabled Dependent Child
- Insurance Marketplace Coverage Options for Eligible New Hires
- Insurance Marketplace Coverage Options for Ineligible New Hires
- Legal Guardianship Certification
- Release of Information Authorization
Flexible Spending Account Forms:
Health Plan of Nevada (HPN) Forms:
Hometown Health Plan (HHP) Forms:
PPO Dental Plan Forms:
Public Records Request Forms:
- Public Records Request Instruction Form
- Public Records Request Form
- Public Records Request Initial Receipt Response
- Release of Information Authorization
- Fee Schedule for Public Records Requests
Standard Insurance Forms:
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
- HealthSCOPE Medical Claim Form
- Hometown Health Prior Authorization Referral 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
Eligibility Forms for All Plans:
- Certification of Disabled Dependent Child
- Legal Guardianship Certification
- Release of Information Authorization
Health Plan of Nevada (HPN) Forms:
Hometown Health Plan (HHP) Forms:
PPO Dental Plan Forms:
Public Records Request Forms:
- Public Records Request Instruction Form
- 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:
PPO Dental Plan Forms:
Public Records Request Forms:
- Public Records Request Instruction Form
- 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
Towers Watson's OneExchange Forms