Form Fa 10D PDF Details

When you're starting a new business, there are many things to consider - one of which is what type of entity to form. There are a number of different types of entities to choose from, and each has its own benefits and drawbacks. In this blog post, we'll take a look at Form Fa 10D - also known as the Delaware Corporation. We'll discuss some of the pros and cons of forming a Delaware Corporation, and help you decide if it's the right choice for your business. Stay tuned!

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)

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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

 

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Part number 1 of submitting neurobehavioral status exam template

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

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