Form Fa 24 PDF Details

The Nevada Medicaid and Check Up Authorization Request for Personal Care Services, known as the FA-24 form, plays a critical role for residents seeking personalized care services under Nevada's Medicaid program. It serves as a comprehensive request form that the providers submit through the Provider Web Portal, encapsulating a broad range of necessary information to evaluate and approve the requisite care services. The form covers various sections, including the purpose of the request, which ranges from routine updates and significant changes in condition to temporary authorizations or cancellations. It meticulously collects recipient and personal care services (PCS) agency information, ensuring every detail from contact information to diagnosis and incidents affecting the individual's abilities are well-documented. Importantly, the form also acknowledges the role of legally responsible individuals (LRI) in the care process, incorporating sections for their information and employment status, besides specifying the need for an alternate contact for scheduling. Diagnosis and recent incidents, including hospitalizations or loss of non-paid caregivers, are required fields aiming to furnish a thorough understanding of the recipient's current health status and needs. Additionally, comments and additional information sections offer space for any extra details that might assist in a more accurate assessment or processing of the request. The FA-24 form thus becomes an essential document, ensuring precision and clarity in communicating the needs of Nevada Medicaid recipients looking for personal care services.

QuestionAnswer
Form NameForm Fa 24
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other names2012, DOB, dissemination, REQUESTER

Form Preview Example

Nevada Medicaid and Check Up

Authorization Request for Personal Care Services (PCS)

Upload this request through the Provider Web Portal.

Questions? Call: (800) 525-2395

For information on completing this form, see the instructions online at www.medicaid.nv.gov (select “Forms” from the “Providers” menu, then click on Form Number FA-24-I).

DATE OF REQUEST: ____/____/______

SECTION 1: FOR NEVADA MEDICAID USE ONLY

SECTION 2: PURPOSE OF REQUEST

Update Visit (annual)

Significant Change in Condition

Temporary Service Authorization

One-Time Service

Information Only

___________________________

___________________________

___________________________

Cancel Authorization

Agency’s last date of service:

____/____/_______

Reason:

Recipient Ineligible

 

Recipient Expired

 

Other: __________________

SECTION 3: CONTACT INFORMATION

RECIPIENT INFORMATION

Last Name:

 

 

First Name:

 

 

 

 

Recipient Medicaid ID:

 

 

Date of Birth:

 

 

 

 

Translator Required:

Yes

No

Language:

 

 

 

 

Address:

 

 

 

City:

State:

Zip Code:

Phone:

PCS AGENCY INFORMATION

PCS Agency Name:

 

City:

 

 

 

 

NPI/API:

Phone:

 

Fax:

 

 

 

 

LEGALLY RESPONSIBLE INDIVIDUAL (LRI) INFORMATION (if applicable*)

*Complete this section if the definition of LRI is met. Individuals who are legally responsible to provide medical support, including spouses of recipients, legal guardians [not power of attorney (POA)], and parents of minor recipients, including stepparents, foster parents and adoptive parents. Attach a completed copy of form FA-24B (LRI Availability Determination for the Personal Care Services Program) with any submitted request when the recipient resides with an LRI. It is the responsibility of the provider to attach a current work note (availability) or a copy of the permanent disability form or an updated disability form if the disability was/is temporary (capability). If this section is not addressed and appropriate paperwork not attached, this request will be denied and the form will be returned to the provider. See the FA-24 Instructions on the Forms webpage at www.medicaid.nv.gov for additional instructions regarding this section.

Does recipient have an LRI? (see definition above)

 

Yes

No

Unknown

 

 

 

 

 

 

 

 

 

 

 

LRI Name:

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

Relationship to Recipient:

 

 

 

 

Does LRI reside with recipient?

Yes

No

 

 

 

 

 

 

 

 

Is the LRI also on the PCS Program:

Yes

No

 

 

 

Receives_________ hrs/wk

 

 

 

 

 

 

 

LRI Employment Status:

Employed

# Hrs/wk:_____ Days Off:_______

Unemployed

Disabled

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FA-24

 

 

 

 

 

 

 

 

Page 1 of 3

Updated 08/23/2021 (pv01/29/2019)

Nevada Medicaid and Check Up

Authorization Request for Personal Care Services (PCS)

Recipient Name:

Recipient Medicaid ID:

ALTERNATE CONTACT INFORMATION

(An alternate contact is needed for scheduling purposes in the event the recipient and/or LRI are unavailable.)

Alternate Contact Name:

Phone:

Relationship to Recipient:

 

 

 

 

 

 

Can this person be contacted in case we are unable to contact recipient?

Yes

No

 

 

 

 

SECTION 4: DIAGNOSES AND INCIDENTS

 

 

 

 

 

 

 

 

 

 

 

DIAGNOSIS/DIAGNOSES AFFECTING THE INDIVIDUAL’S ABILITY TO COMPLETE TASKS:

Is anyone else in the home receiving PCS at this time?

 

 

Yes - Who:_________________________________________________

No

Unknown

INCIDENTS, INCLUDING A SUMMARY OF ALL REPORTED SERIOUS OCCURRENCES, WITHIN PAST 90 DAYS (Check all that apply. The Summary of Reported Serious Occurrences section is mandatory.)

Hospitalization

Discharged date or anticipated discharge date: ________________________

 

 

 

 

Recent Fall

 

Surgery Type:________________________________

Loss of non-paid caregiver

 

 

 

New Medical Condition/Diagnosis (specify):

 

 

 

Addition or loss of other services (specify):

 

Summary of Reported Serious Occurrences: ________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

No Serious Occurrences

SECTION 5: COMMENTS (General comments that would assist an assessor in completing an accurate assessment; include reason for request):

SECTION 6: PERSON COMPLETING/SUBMITTING THIS REQUEST (This person will be contacted with questions or if additional information is needed to process this request.)

Name:

Phone:

FA-24

Page 2 of 3

Updated 08/23/2021 (pv01/29/2019)

 

Nevada Medicaid and Check Up

Authorization Request for Personal Care Services (PCS)

SECTION 7: PERSONAL CARE ATTENDANT (PCA) INFORMATION (An LRI cannot be a PCA) (Mandatory fields)

PCA Name:

PCA Phone Number:

 

 

(cannot be the agency’s phone number)

 

 

 

 

 

 

 

 

 

PCA is a relative:

Yes

No

If Yes, what is the relationship:

 

 

 

 

 

 

 

 

 

PCA resides:

In home

Out of home

 

PCA is not related but lives in home:

Yes

No

 

 

 

 

 

 

PCA is not related and is not living with recipient:

Yes

No

 

 

 

 

 

 

 

 

 

SECTION 8: ADDITIONAL COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The information contained in this form, including 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 has been received in error, the reader shall notify sender immediately and shall destroy all information received. This referral/authorization is not a guarantee of payment.

FA-24

Page 3 of 3

Updated 08/23/2021 (pv01/29/2019)

 

How to Edit Form Fa 24 Online for Free

It won't be challenging to obtain FA-24 working with our PDF editor. Here's how you can easily easily design your file.

Step 1: Click on the button "Get Form Here".

Step 2: At the moment, it is possible to alter your FA-24. Our multifunctional toolbar makes it possible to include, delete, adapt, highlight, as well as undertake other commands to the words and phrases and fields within the form.

Provide the content demanded by the application to complete the file.

part 1 to filling out hp enterprise services healthcare nevada

Note the necessary data in the field Recipient Ineligible Recipient, SECTION CONTACT INFORMATION, RECIPIENT INFORMATION, Last Name, Recipient Medicaid ID, Translator Required, Yes, First Name, Date of Birth, Language, Address, City, State, Zip Code, and Phone.

part 2 to finishing hp enterprise services healthcare nevada

It's important to provide specific particulars within the space LEGALLY RESPONSIBLE INDIVIDUAL LRI, Does recipient have an LRI see, Yes, Unknown, LRI Name, Relationship to Recipient, Phone, Does LRI reside with recipient, Yes, Is the LRI also on the PCS Program, Yes, No Receives hrswk, LRI Employment Status, Employed Hrswk Days Off, and Unemployed.

part 3 to filling out hp enterprise services healthcare nevada

The space Nevada Medicaid and Check Up, Recipient Name, Recipient Medicaid ID, ALTERNATE CONTACT INFORMATION An, Alternate Contact Name, Phone, Relationship to Recipient, Can this person be contacted in, Yes, SECTION DIAGNOSES AND INCIDENTS, DIAGNOSISDIAGNOSES AFFECTING THE, Is anyone else in the home, Yes Who, Unknown, and INCIDENTS INCLUDING A SUMMARY OF is where you include all parties' rights and responsibilities.

part 4 to completing hp enterprise services healthcare nevada

Finalize by reviewing these sections and filling them in as required: Recent Fall, Surgery, Type, Loss of nonpaid caregiver, New Medical ConditionDiagnosis, Addition or loss of other services, Summary of Reported Serious, No Serious Occurrences, and SECTION COMMENTS General comments.

hp enterprise services healthcare nevada Recent Fall, Surgery, Type, Loss of nonpaid caregiver, New Medical ConditionDiagnosis, Addition or loss of other services, Summary of Reported Serious, No Serious Occurrences, and SECTION COMMENTS General comments blanks to fill

Step 3: Click the Done button to save your document. Now it is at your disposal for export to your electronic device.

Step 4: It may be simpler to have duplicates of the file. You can rest easy that we are not going to display or see your particulars.

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