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.

Forms & Documents

2022 Pre-Enrollment Checklist for Northern Nevada Plans (English | Spanish)

2022 Pre-Enrollment Checklist for Northern Nevada Plans (English | Spanish)

2022 Pre-Enrollment Checklist for Encompass Plan (English)

2022 Enrollment Form for Northern Nevada Plans (Patriot, Essential, Select) (English)

2022 Enrollment Form for Renown Preferred Plan (English)

2022 Enrollment Form for Comprehensive & Encompass Plans (English)

2022 Enrollment Form for Complete Plan (English)

2022 Over-the-Counter Catalog (English)

2022 Over-the-Counter Order Form (English)

2020 Medicare Advantage Enrollment Application – Washoe County & Carson City County
2020 Medicare Advantage Enrollment Application – Washoe County & Carson City County – Spanish
Members new to Senior Care Plus that live in Washoe County or Carson City County, NV would complete this form along with Medicare Card information and submit it to Senior Care Plus.

2020 Medicare Advantage Enrollment Application – Clark County & Nye County
2020 Medicare Advantage Enrollment Application – Clark County & Nye County – Spanish
Members new to Senior Care Plus that live in Clark County or Nye County, NV would complete this form along with Medicare Card information and submit it to Senior Care Plus.

2020 Annual Abbreviated Election Form 
2020 Annual Abbreviated Election Form – Spanish
For existing members in Washoe County to elect 2019 plan options.

Medical Claim Form
For individuals who need to submit a medical claim.

Medicare Part B Form
For individuals who need to sign up for Medicare Part B (Medical Insurance).

2020 Over-the-Counter (OTC) Catalog

For member who have an OTC benefit.

2020 Over-the-Counter (OTC) Order Form

For members with an OTC benefit.
Request a Provider and Pharmacy Directory
For members who would like a Provider/Pharmacy Directory mailed to their home. Please have your member number ready.

2019 Premium Pay Change Form
If an existing member would like to change his or her premium payment option to direct self pay (using coupon slips), electronic funds transfer (EFT) or Social Security check withholding, the member would complete the form, with the effective date, and submit it to Senior Care Plus.

HIPAA – Written and Verbal Authorization 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.

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.

Appointment of Representative Form – Spanish
If an existing member would like to appoint a representative to make any request or obtain appeals information, the member would complete the form and submit it to Senior Care Plus.

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.

Prior Authorization Form
Form used by provider to request a prior authorization.

Provider Claim and Authorization Reconsideration Form
Form used by a provider for authorization reconsideration.

Coverage Determination Request

Multi-Language Interpreter Services
The Multi-Language Insert is a document that contains information translated into multiple languages: (e.g., Spanish, Chinese, Tagalog, French, Vietnamese, German, Korean, Russian, Arabic, Italian, Portuguese, French Creole, Polish, Hindi, and Japanese).