Please rate Form Fa 24 07-21-2026
This referral/authorization is not a guarantee of payment.
Transfers: complete Section 2: A and page 3.
IADLs: only authorized in conjunction with ADL services, and when an LRI is not available or capable of performing the IADLs.
Alternate contact: needed for scheduling purposes in the event the recipient and/or LRI are unavailable.
Contact: Gainwell Technologies Prior Authorization Contact Center: (800) 525-2395.
| Question | Answer |
|---|---|
| Form Name | Form FA-24 |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 109 |
| Avg. time to fill out | 19 min |
| Edition | Updated 07/21/2026 |
| Issuing agency | Nevada Medicaid and Check Up |
| Where to send | Upload through the Provider Web Portal |
| Other names | FA-24, FA24, Form FA-24, FA 24, Nevada Medicaid FA-24, Authorization Request for Personal Care Services |
| Official source | Form FA-24 (Rev 07/21/2026), Nevada Medicaid and Check Up |
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Please rate Form Fa 24 07-21-2026
