Member Forms​

Member Service & Support

Can’t find what you need? Give us a call at 800-336-0123

Right of Access

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 the member should complete this form and submit it to Hometown Health.

Continuity of Care Request Form

Use this form to request extended care from your current health care professional if he or she has left the health plan network and is now considered out-of-network.

Medical Claim 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.

Optum Rx Commercial Prescription Drug Claim Form

If an existing member needs to request reimbursement for a prescription that they paid for out-of-pocket, the member would complete this form.  Once complete, submit the form with pharmacy receipt(s) to: Optum Rx Claims Department, PO Box 650629, Dallas, TX 75265-0629

Physician Nomination Form – HMO and PPO

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