Enrollment Change Form

• Used to make changes to group’s enrollment, i.e., add, terminate or change an employee or dependent’s coverage.

Enrollment Change Form – Spanish

• Used to make changes to group’s enrollment, i.e., add, terminate or change an employee or dependent’s coverage.

Waiver of Health Coverage Benefits

• Use this form for each employee who is waiving coverage. Be sure to have the employee provide a copy of his or her insurance card, if applicable.

Waiver of Health Coverage Benefits – Spanish

• Use this form for each employee who is waiving coverage. Be sure to have the employee provide a copy of his or her insurance card, if applicable.

Group Eligibility and Payment Provisions

• Used during the open enrollment period to make changes to eligibility provisions.

Cobra Continuation Election Form

• Used to elect Cobra after a qualifying termination for an Employer group with 20 or less employees.

HIPAA – Written and Verbal Authorization 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 or in writing, the member would complete this form and submit it to Hometown Health.

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.

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.

Physician Nomination Form HMO & EPO
Physician Nomination Form 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.