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.
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.
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.
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
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.
Hometown Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.