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Health Plan of Nevada

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    • 12 Tips About Your Plan
    • Care Management
    • Disease Management
    • Enroll in an Individual Plan
    • Flu Shot Locations
    • Frequently Asked Questions
    • Health Education and Wellness
    • Health Plan Forms
    • Health Plan ID Card
    • Healthy Recipes
    • HPN & SHL Mobile App
    • Individual Renewal Options
    • IRS Form 1095-B
    • Medicaid - Enroll
    • Medicaid – Member Plan Information
    • Medicare Options
    • Member Guide (PDF)
    • Mental Health And Substance Use Benefits
    • My Health Plan
    • My Plan Documents
    • One Pass Select
    • Online Member Center
    • Pregnancy Through Childhood
    • Preventive Services
    • Required Notices
    • Taking On Healthy Digital Newsletter
    • Weight Loss Program
    • Prescription Drug Lists
    • Prescription Drug Coverage
    • 90-Day Prescription Supply
    • Vital Medication Program
    • Zero Cost Share List
    • 24/7 Advice Nurse
    • 24/7 Virtual Visits (NowClinic®)
    • Dental
    • Doctor or Provider
    • Freestanding ER
    • Hospitals and ERs
    • Mental Health and Substance Use
    • Same Day Medical Care
    • Urgent Care Locations
    • Vision
    • Where to Go For Care

Health Plan Forms

Download and print the health plan form you need

  • 2025 Individual Off Exchange Application Form (PDF)
  • 2025 Individual Off Exchange Member Change Form (PDF)
  • 2025 Nevada Small Group (1-50) Application Form (PDF)
  • 2025 Nevada Large Group (51+) Application Form (PDF)
  • Applied Behavioral Analysis (ABA) Authorization Form (PDF)
  • Authorization for the Release of Protected Health Information (PDF)
  • AZ Prior Authorization Request Form (PDF)
  • Behavioral Health Injectable Antipsychotic Prior Authorization Form (Genoa Pharmacy) (DOC)
  • Coordination of Benefits Form (PDF)
  • Employee Enrollment and Change Form (PDF)
  • Employee Enrollment and Change Form - Spanish (PDF)
  • Medical Necessity Request Form (PDF)
  • Nevada Claim Form (PDF)
  • New Prescription Fax Order Form (PDF)
  • Primary Care Physician Change Request Form (PDF)
  • Pharmacy Reimbursement Claim Form (PDF)
  • QOC Internal Referral Form (PDF)
  • Substance Abuse Records Release Form (PDF)
  • Transition of Care and Continuity of Care Form (PDF)

If you don't see the form you're looking for, please call the Member Services number on the back of your health plan ID card.

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