Forms and Documents

If you would like to print the forms and documents yourself, please use the attachments below. Please complete the forms and address them to the appropriate individual. If mailing to Senior Care Plus, please address the form to: Senior Care Plus, 10315 Professional Circle Reno, NV 89521.

We encourage you to contact Senior Care Plus if you have any questions or concerns regarding your health care benefits. We can assist you with benefit questions, service issues, and problem resolution, as well as any form requests.

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.

Medical Claim Form

Medicare Part B Form

For individuals who need to submit a medical claim. Updated 01/01/22

English Medicare Part B Form

Spanish Medicare Part B Form

Pharmacy Forms & Coverage Determination Request

Use the link below to access pharmacy related forms from our Pharmacy Benefit Manager, Optum Rx.

View Optum RX Forms

Right of Access Form

If an existing member would like to authorize Hometown Health / Senior Care Plus 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 / Senior Care Plus. Updated 12/01/21

Right of Access Form

Appointment of Representative Form

If an existing member would like to authorize Senior Care Plus to use and/or disclose the member’s health and medical information to a personal representative, the member would complete the form and submit it to Senior Care Plus. Following this link will take you out of the www.SeniorCarePlus.com website. Updated 08/01/18

English Appointment of Representative Form

Spanish Appointment of Representative Form

Residence Verification

If the Centers for Medicare & Medicaid Services or Senior Care Plus need to verify your permanent place of residence, the member would complete the form and submit it to Senior Care Plus. Updated 03/01/22

Residence Verification Form

Prior Authorization Form
(Utilization Managment)

Form used by provider to request a prior authorization. Updated 01/11/24

Prior Authorization Form (Providers)

Continuation of Care - Utilization Managment Form (Members)

Provider Claim & Authorization Reconsideration Form

Form used by a provider for authorization reconsideration. Updated 01/01/20

Provider Claim & Authorization Reconsideration Form

Request a Directory or Document

Click the link below to request a directory or a document.

Document Request Form

NOTICE OF MEDICARE NON-COVERAGE

HHAs, SNFs, Hospices, and CORFs are required to provide a Notice of Medicare Non-Coverage (NOMNC) to beneficiaries when their Medicare covered service(s) are ending.

The NOMNC informs beneficiaries on how to request an expedited determination from their Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) and gives beneficiaries the opportunity to request an expedited determination from a BFCC-QIO. A Detailed Explanation of Non-Coverage (DENC) is given only if a beneficiary requests an expedited determination.

The DENC explains the specific reasons for the end of covered services.

To download the NOMNC and DENC, please click on the appropriate link below in “Downloads”.
Full instructions for the Original Medicare, also known as Fee for Service (FFS), expedited determination process are available in Section 260, of Chapter 30 of the CMS Claims Processing Manual, available below in “Downloads”.

Here is the Requirements that go into effect 1/1/2025: FFS & MA NOMNC/DENC | CMS

Skilled Nursing - Notice of Medicare Non-Coverage

Home Health - Notice of Medicare Non-Coverage