Skip to main content
Health Plan of Nevada, A UnitedHealthcare Company, Nevada Public Employees' Benefits Program
    • 12 Tips About Your Plan
    • Disease Management
    • Health Care Terms
    • Health Education and Wellness
    • Health Plan Forms
    • Health Plan ID Card
    • Hospital Stay
    • IRS Form 1095-B
    • Member Guide (PDF)
    • My Health Plan
    • My Plan Documents
    • HPN & SHL Mobile App
    • Online Member Center
    • Preventive Services
    • Prior Authorization
    • Real Appeal
    • Referrals From My Doctor
    • Update PCP/Doctor
    • Update Personal Information
    • Update/Remove Dependents
    • Where To Go For Care
    • Drug Lists
    • Pharmacy Benefits
    • 24/7 Advice Nurse
    • 24/7 Virtual Visits
    • Doctor or Provider
    • Freestanding ER
    • Hospitals
    • Mental Health and Substance Use
    • Same Day Medical Care
    • Urgent Care
    • Vision
    • Where To Go For Care
Sign In
Sign In
×

More Sites

Health Plan of Nevada, A UnitedHealthcare Company, Nevada Public Employees' Benefits Program
Site Search ×
Home ×
    • 12 Tips About Your Plan
    • Disease Management
    • Health Care Terms
    • Health Education and Wellness
    • Health Plan Forms
    • Health Plan ID Card
    • Hospital Stay
    • IRS Form 1095-B
    • Member Guide (PDF)
    • My Health Plan
    • My Plan Documents
    • HPN & SHL Mobile App
    • Online Member Center
    • Preventive Services
    • Prior Authorization
    • Real Appeal
    • Referrals From My Doctor
    • Update PCP/Doctor
    • Update Personal Information
    • Update/Remove Dependents
    • Where To Go For Care
    • Drug Lists
    • Pharmacy Benefits
    • 24/7 Advice Nurse
    • 24/7 Virtual Visits
    • Doctor or Provider
    • Freestanding ER
    • Hospitals
    • Mental Health and Substance Use
    • Same Day Medical Care
    • Urgent Care
    • 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 Association Group Health Plan Application for State of Nevada (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.

HELPFUL LINKS
  • Accessibility
  • Careers
  • Fraud, Waste and Abuse
  • IRS Form 1095-B
  • Privacy
  • Quality
  • Terms of Use
PARTNERS
  • Behavioral Healthcare Options
  • Southwest Medical
Contact Us
  • face book
  • insta

Copyright © 2025 United HealthCare Services, Inc. All rights reserved.