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Nevada Public Employees' Benefits Program

State Agencies State Jobs ADA Assistance

Forms

Eligibility Forms for All Plans

Insurance Marketplace Coverage Options for Eligible New Hires PY24

Insurance Marketplace Coverage Options for Ineligible New Hires PY24

Certification of Disabled Dependent Child

Guardianship to Age 26 Certification Form

Release of Information Authorization

Retiree Benefit Enrollment and Change Form

Years of Service Form

Benefit Enrollment and Change Form Unsubsidized

Travel Pre-Authorization Form

Travel Reimbursement Form

Appeal Forms

External Review Request Form

Internal Claim Appeal Request Level 2

Expedited Review Form

Physician Certification of Experimental/Investigational Denials Form

Consumer Driven Health Plan (PPO) Forms

Express Scripts RX Reimbursement Claim Form

Express Scripts RX Mail Order Delivery Form

UMR Medical Claim Form

Obesity Care Management Initial Evaluation Form

Diabetes Care Management Form

HSA Designation of Beneficiary Form

HSA Direct Transfer Request Form

HSA Application and Eligibility Form

HRA Reimbursement Request Form

Transition of Care & Continuity of Care Form

Flexible Spending Account Forms

Flexible Spending Enrollment Form

Health Care and Dependent Care Reimbursement Request Form

Direct Deposit Authorization Form

Health Plan of Nevada (HMO) Forms

Non-Plan Provider Claim Form

Optum Pharmacy Mail Order Form

Optum Pharmacy Reimbursement Form

HRA Reimbursement Request Form

Low Deductible Plan (PPO) & Exclusive Provider Organization Plan (EPO) Forms:

Express Scripts RX Reimbursement Claim Form

Express Scripts RX Mail Order Delivery Form

UMR Medical Claim Form

HRA Reimbursement Request Form

Transition of Care & Continuity of Care Form

Basic Life Insurance Forms:

United Healthcare is the plan administrator for the basic life insurance policy provided to eligible active and retired members. For basic life insurance death claims where the participant was deceased prior to 7/1/2022 contact The Standard—Customer Service: 1-888-288-1270.

Accelerated Death Life Insurance Benefit

Life Claim Form

Waiver of Premium Form

The Standard Insurance Forms for Voluntary Life Insurance

Group Life Conversion Form

Group Life Portability Form

Life Insurance Claim Form

PEBP Vaccine Clinic Consent Form

Informed Consent for Immunization with Inactivated & Live Vaccines

Spanish Version Informed Consent for Immunization & Live Vaccines

Frequently Asked Questions (FAQs)

Health and Wellness

Public Records Request

Community Resources

Fiscal & Utilization Reports

Newsletters and Mailings