Form Fa 24 – Fill Out and Use This PDF

Form Fa 24 is a Spanish form that's used by the IRS to report compensation received and taxes withheld from an employee.

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Form Fa 24 PDF Details

Every year, as required by law, businesses large and small must file IRS Form Fa 24. This information is used to calculate how much each business owes in taxes. While it can seem like a daunting task, with the help of a professional accountant, it's a process that can be completed relatively easily. Here we'll outline what information is required on Form Fa 24, and what penalties you could face if you don't submit it on time.

Here, you'll find a number of details about form fa 24 PDF. This site can provide specifics of the form's size, finalization duration, and the parts you can be expected to fill.

Question	Answer
Form Name	Form Fa 24
Form Length	3 pages
Fillable?	Yes
Fillable fields	92
Avg. time to fill out	19 min 13 sec
Other names	REQUESTER, DOB, API, 2011

12

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)

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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, INFORMATION LastName, Recipient, Medicaid, ID Translator, Required Yes, First, Name DateofBirth, Language, Address, City, State, Zip, Code Phone, PCS, AGENCY, INFORMATION and PCS, Agency, Name

part 2 to finishing hp enterprise services healthcare nevada

It's important to provide specific particulars within the space Recipient, Name Recipient, Medicaid, ID Alternate, Contact, Name Phone, Relationship, to, Recipient Yes, SECTION, DIAGNOSES, AND, INCIDENTS Yes, Who Unknown, and Hospitalization.

part 3 to filling out hp enterprise services healthcare nevada

The space Recent, Fall Surgery, Type, Loss, of, non, paid, caregiver New, Medical, Condition, Diagnosis, specify Summary, of, Reported, Serious, Occurrences and No, Serious, Occurrences 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: Name, Phone, FA, Updated, pv and Page, of

hp enterprise services healthcare nevada Name, Phone, FAUpdatedpv, and Pageof blanks to fill

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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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