Fa-24-I 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.

QuestionAnswer
Form NameForm Fa 24
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespv10, PCS, FA-24-I, FA-24

Form Preview Example

HP Enterprise Services - Nevada Medicaid and Check Up

Functional Assessment Request for Personal Care Services (PCS)

 

 

Fax to: (775) 335-8592

Questions? Call: (800) 525-2395

 

DATE OF REQUEST: _____ /______ /______

 

REQUESTER NAME:

________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PURPOSE OF REQUEST

 

 

 

 

 

 

 

 

 

 

 

 

Initial Visit*

 

 

Transfer Provider

 

Cancel Authorization

 

 

Re-certification Visit**

 

 

Transfer Start Date:

 

Cancellation Date: ______/______/________

 

 

Update Visit (Q year)***

 

____/______/_________

 

Reason:

Recipient Ineligible

 

 

One Time Service

 

 

 

 

Recipient Expired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other: _____________________

 

 

RECIPIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

Last Name, First Name, Middle Initial:

 

 

 

 

 

 

 

 

Recipient ID:

 

 

 

 

 

Translator Required

Language:

 

 

SSN:

 

 

 

 

 

DOB:

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

City:

State:

 

Zip Code:

 

 

Phone:

 

 

 

GUARDIAN INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

Guardian Name (if applicable):

 

 

 

 

 

 

 

Relationship to Recipient:

 

 

Guardian Address:

 

 

 

 

 

 

 

Phone:

 

 

 

 

City:

State:

 

Zip Code:

 

 

Fax:

 

 

 

PCS AGENCY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

PCS Agency Name:

 

 

 

 

 

 

API:

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

City:

State:

 

Zip Code:

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

Fax:

 

 

 

 

REFERRAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

State:

 

Zip Code:

 

 

 

 

 

 

Phone:

 

 

Fax:

 

 

 

 

 

 

REASON FOR REQUEST (Required for Initial Visits, Re-certification Visits and One Time Requests)

Description of service and recipient needs (has homemaker, surgery scheduled, etc.):

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

*Initial Visit: The recipient has no current functional assessment or service plan.

**Re-certification Visit: The recipient’s needs have changed within the one-year update period due to, e.g., surgery, health issues, recovery, loss of caretaker in home.

***Update Visit: The yearly review of a recipient’s service plan and functional assessment. A new Authorization Number is given to the provider.

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

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

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03/07/2012 pv10/01/2011

 

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