Employer Forms
For Employers
Enrollment/Change Form – Spanish
Used to initially enroll members or make changes to a member’s enrollment, i.e. add, terminate, or change an employee or dependent’s coverage.
Enrollment/Change Form
Used to initially enroll members or make changes to a member’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.
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.
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.
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.
Prescription Drug Forms
Optum Rx has a number of different forms for Hometown Health members. Click below to access a Claim Form, Prior Authorization Form, or a Step Therapy Exemption Form.
