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Provider Intent Form
  • Welcome!
  • 1. Provider Info
  • 2. Location(s)
  • 3. Additional Info
  • 4. Submit!
Welcome to the Hometown Health Provider Intent Form!
Existing Providers
requesting to be added to an existing contract with Hometown Health.
If a provider needs to be added to an existing contract with Hometown Health, please start here.
Delegates
Hometown Health delegates Dental, Vision, and services outside of Nevada.
If you are interested in applying to become a contracted provider for these services please start here.
Dental - If you wish to provide services to our membership we ask that you contact the following Dental networks directly to apply.
  • Diversified Dental
  • United Health Care
  • Guardian
  • Metlife
  • Liberty
Vision - If you wish to provide services to our membership we ask that you contact VSP directly on their provider hub.
Outside of NV - If you wish to provide services to our membership outside of Nevada we utilize the PHCS network. You may contact them to become a provider here.
New Providers
We are excited that you are interested in joining our quality network of physicians and health professionals.
Please complete the following form to submit a request as a provider, or on behalf of a provider, to become part of Hometown Health's provider network!
The form only takes minutes to complete!
What information do I need?
Provider Info
Specialty Type



Requestor Info
Phone:
•
•
Ext
Add up to five (5) different locations (at least one (1) is required).
+ Add Location
1.) Is this provider a member of group?
2.) Does this provider have any hospital affiliations? If so, please list facilities:
3.)
Please tell us any additional information about your practice that may help Hometown Health make a decision:
You are ready to submit your application!
Please review your application before submitting.
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Thank you!

Your request to become part of Hometown Health's provider network has been successfully submitted. You should be hearing back from us in the next 45-60 business days (excluding holidays).

You should also be receiving an email acknowledging that your request has been submitted. If you do not receive this email, please check your spam or junk folder and be sure to add us to your "safe sender" list.

We're sorry, but there's been an error.

We apologize for any inconvenience this may have caused. Please see the below error.

Click here to start over.

  • Provider name (first and last), title, degree, and specialty.
  • Provider's tax ID and NPI identification numbers.
  • At least one (1) location, including address, phone, fax, email, and contact name.
  • If applicable, group name and any hospital affiliations.
  • Any additional information that may be useful in helping Hometown Health make a determination.
[remove this location]
Location Info


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