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