Member Forms
Member Service & Support
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.
Reimbursement Claim Form
Use this form for reimbursement out-of-pocket claims expense. Download the form, read the instructions and then complete the front side of the form. You will need to have the physician or facility fill out the back of the form. Once complete, submit it to Hometown Health’s Customer Service department by following the instructions on Claims Department by emailing to Customer_Service@hometownhealth.com or faxing to 775-982-3751.
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.
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