Form Fa 10D PDF Details

In the complex landscape of healthcare and insurance, the Fa 10D form serves a crucial role for patients requiring specialized medical evaluations, specifically the Neurobehavioral Status Exam under the auspices of Nevada Medicaid and Nevada Check Up programs. This form, a Prior Authorization Request, streamlines the process for healthcare providers to secure requisite approval for conducting these critical examinations, which are pivotal in diagnosing and planning the care for various neurobehavioral conditions. The form meticulously captures essential data ranging from patient and referring provider information to detailed clinical specifics about the examination required, including the number of units of code 96116 requested and any prior testing information. It is designed to facilitate communication and documentation between healthcare professionals and the administrative entities of Medicaid, ensuring clarity in the services provided. Additionally, it underscores the importance of adhering to procedural guidelines, as evident in its explicit mention that authorizations granted are not an implicit guarantee of payment but are contingent upon a constellation of eligibility criteria, contractual stipulations, and other benefits-related terms and conditions. The document also emphasizes confidentiality and data protection, underscoring the sensitivity of the patient information handled throughout the authorization process. With its comprehensive coverage and structured approach, the Fa 10D form embodies the intricate intersection between healthcare delivery and administrative processes, aiming to enhance the efficiency and effectiveness of patient care within the regulatory framework of Nevada's healthcare programs.

QuestionAnswer
Form NameForm Fa 10D
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform fa 10d neurobehavioral status exam, neurobehavioral status exam template, cognistat pdf, cognistat assessment forms

Form Preview Example

 

 

 

 

Prior Authorization Request

 

HP Enterprise Services - Nevada Medicaid and Nevada Check Up

 

Neurobehavioral Status Exam

 

 

 

 

 

(code 96116)

Fax this request to: (866) 480-9903

 

 

 

 

 

Questions? Call: (800) 525-2395

DATE OF REQUEST: ______ /______ /________

 

 

 

 

 

 

 

 

 

 

 

RECIPIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recipient Name (Last, First, MI):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recipient ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

DOB:

 

Address:

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

City:

State:

 

 

 

 

 

 

 

 

 

Zip Code:

 

Responsible Party Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

City:

State:

 

 

 

 

 

 

 

 

 

Zip Code:

 

REFERRING PROVIDER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referring Provider Name:

 

 

 

 

 

 

 

 

 

NPI:

 

Phone:

 

 

 

 

 

 

 

 

 

Fax:

 

PSYCHOLOGIST INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychologist Name:

 

 

 

 

 

 

 

 

 

NPI:

 

Phone:

 

 

 

 

 

 

 

 

 

Fax:

 

CLINICAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Scheduled Date of Neurobehavioral Status Exam:

 

 

 

 

 

 

 

 

 

 

 

Number of 96116 Unit Requested:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has previous testing been performed?

 

 

No

 

Yes: If yes, date: ____/____/_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this request for Healthy Kids (EPSDT) services?

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current symptoms and relevant history:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referral Question (specific reason for referral):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Requested Procedures/Methods

 

 

 

 

 

 

 

Requested Procedures/Methods (CONTINUED)

1.

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

7.

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

8.

 

 

 

 

 

 

 

 

Requesting Provider Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HP ENTERPRISE SERVICES USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Codes and Units Approved:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Approved From:

 

 

 

 

 

 

 

Approved Through:

 

Codes and Units Denied:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Denied From:

 

 

 

 

 

 

 

Denied Through:

 

Reviewer Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions, coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.

FA-10D

Page 1 of 1

10/01/11

 

How to Edit Form Fa 10D Online for Free

Working with PDF files online is surprisingly easy with this PDF tool. Anyone can fill in NPI here within minutes. Our editor is continually evolving to deliver the very best user experience possible, and that is because of our dedication to continuous improvement and listening closely to comments from customers. To get started on your journey, go through these easy steps:

Step 1: Open the PDF form inside our tool by clicking on the "Get Form Button" in the top section of this webpage.

Step 2: When you open the editor, you will see the form made ready to be filled in. In addition to filling in various fields, you may as well do some other things with the file, specifically adding any textual content, changing the original textual content, inserting illustrations or photos, placing your signature to the form, and much more.

Filling out this document needs attentiveness. Make sure that every single field is done properly.

1. Begin filling out the NPI with a selection of essential blank fields. Collect all the required information and ensure nothing is omitted!

Part number 1 of submitting neurobehavioral status exam template

2. Once the prior selection of blank fields is completed, go on to enter the relevant information in all these: Fax this request to Questions, Yes If yes date, Yes, Date, and Requested ProceduresMethods.

Find out how to fill in neurobehavioral status exam template stage 2

Always be extremely attentive when filling out Date and Yes, because this is where many people make errors.

Step 3: When you've reread the information in the blanks, just click "Done" to conclude your document creation. Obtain your NPI after you join for a free trial. Instantly view the pdf file inside your personal cabinet, with any modifications and changes being conveniently synced! FormsPal offers risk-free form completion devoid of personal information recording or sharing. Rest assured that your information is in good hands with us!

Form Fa 10D isn’t the one you’re looking for?

Related Documents