Forms

To print the forms yourself, please use the attachments below.  Please complete the forms and address them to the appropriate individual or department. Please address the form to: Hometown Health, Department Name, 830 Harvard Way, Reno, NV 89502.  

Written Authorization Form - View Form
If an existing member would like to authorize Hometown Health to use and/or disclose the member's health and medical information to a personal representative in writing, the member would complete the form and submit it to Hometown Health.    

Verbal Authorization Form - View Form
If an existing member would like to authorize Hometown Health to use and/or disclose the member's health and medical information to a personal representative verbally, the member would complete the form and submit it to Hometown Health. 

Claim Form - View Form 
If an existing member would like to submit a claim for out-of-network services or if you paid for a service out-of-pocket instead of presenting your insurance card at the time of service. The member would complete the front side of the form and have the physician or facility fill out the back of the form and then submit it to Hometown Health's Claims Department. 

Student Verification Form - View Form
If an existing member needs to send verification that a dependent is a full-time student with an accreditted school, the member would complete the form, have it notorized and submit it to Hometown Health's Enrollment Department. 

Direct Member Reimbursement form for Catalyst RX Claims - View Form
If an existing member needs to request reimbursement for a prescription a member had filled and paid out-of-pocket.  

Blank Mail Order Prescription Form - View Form

If an existing member needs to request a new prescription from the RX mail order service.

Physician Nomination Forms - View HMO Form     View PPO Form   

View National/Southern Nevada Network Form 

If your doctor is not in our network you can ask to nominate him or her to be considered for joining our network. Click on the appropriate network form above and follow the instructions to submit it.