Nevada Form Fa 6 PDF Details

Are you filing your taxes in Nevada and looking for the form you need to make sure everything is done correctly? The Nevada Form Fa 6 is an important tool for anyone who wants to pay their state taxes properly and on time. This quick guide will provide a brief overview of what exactly this form represents, as well as how you can use it properly when submitting your taxes. Whether you’re a first-time tax filer or a seasoned pro, this article will give you all the information you need about the Nevada Form Fa 6. Read on for more!

QuestionAnswer
Form NameNevada Form Fa 6
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesapplicable, EPSDT, Nevada, contractual

Form Preview Example

Prior Authorization Request

HP Enterprise Services - Nevada Medicaid and Nevada Check Up

Outpatient Medical/Surgical

(Use Form FA-7 for Outpatient Rehabilitation and Therapy Services)

Fax this request to:

(866) 480-9903

For questions regarding this form, call: (800) 525-2395

DATE OF REQUEST: ______ /______ /________

 

 

REQUEST TYPE:

Initial

Continued Services

Retrospective*

Unscheduled Revision

*REQUIRED FOR RETROSPECTIVE REVIEWS ONLY

This recipient was determined eligible for Medicaid benefits on: ______ /______ /________

RECIPIENT INFORMATION

Recipient Name (Last, First, MI):

Recipient ID:

 

 

 

DOB:

Address:

 

 

 

Phone:

City:

 

State:

 

Zip Code:

Medicare Insurance Information:

Part A

Part B

Medicare ID#:

Other Insurance Name:

 

 

Other Insurance ID#:

Responsible Party Name (if applicable):

Responsible Party Address:

Phone:

ORDERING PROVIDER INFORMATION

Ordering Provider Name:

NPI:

Address:

City:

 

 

 

 

 

State:

 

 

 

Zip Code:

Phone:

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERVICING PROVIDER INFORMATION

 

 

 

 

 

 

 

 

 

 

Servicing Provider Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

State:

 

 

 

Zip Code:

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLINICAL INFORMATION (attach additional sheets if necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of

 

 

 

 

 

 

 

 

 

HP ENTERPRISE

 

 

Code

 

 

 

 

 

 

 

 

 

 

SERVICES USE ONLY

 

 

 

 

Units

 

 

Description of Service

 

 

 

 

 

 

 

 

 

 

 

Requested

 

 

 

 

 

 

Units

 

 

 

 

 

 

 

 

 

Requested

 

 

 

 

 

 

 

 

 

Status

 

Action Code

 

 

 

 

 

 

 

 

 

 

 

 

Approved

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FA-6

Page 1 of 2

10/01/11

 

 

Prior Authorization Request

HP Enterprise Services - Nevada Medicaid and Nevada Check Up

Outpatient Medical/Surgical

(Use Form FA-7 for Outpatient Rehabilitation and Therapy Services)

Is the service you are requesting a hospice benefit?

Yes

No

 

Are you requesting Healthy Kids (EPSDT) referral/services?

Yes

No

Conditions/Symptoms (include ICD-9 codes and descriptions):

 

 

Previous Treatment/Services (include dates):

Results of Previous Treatment/Services:

Other Clinical Information (to support medical necessity of the requested services):

HP ENTERPRISE SERVICES USE ONLY

Approved From:

Approved Through:

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-6

Page 2 of 2

10/01/11

 

 

How to Edit Nevada Form Fa 6 Online for Free

With the help of the online PDF tool by FormsPal, you can easily fill out or change eligibility here. To retain our editor on the cutting edge of efficiency, we work to implement user-oriented features and improvements regularly. We're routinely glad to get feedback - help us with revampimg PDF editing. With just several simple steps, you'll be able to start your PDF editing:

Step 1: Simply click on the "Get Form Button" above on this page to see our pdf file editing tool. This way, you will find all that is needed to fill out your document.

Step 2: This tool lets you work with PDF documents in many different ways. Transform it by writing your own text, adjust existing content, and add a signature - all within the reach of several mouse clicks!

This form will require you to enter specific details; to ensure accuracy, be sure to take into account the following steps:

1. Fill out your eligibility with a number of essential blanks. Gather all of the necessary information and make sure absolutely nothing is neglected!

Writing part 1 of applicable

2. When the previous part is complete, you're ready put in the essential details in DATE OF REQUEST REQUEST TYPE, Zip Code, State, State, Zip Code, Code, Requested, No of Units, Requested, Description of Service, HP ENTERPRISE, SERVICES USE ONLY Units, Status Action Code, and Approved allowing you to go further.

Filling out part 2 in applicable

3. Through this stage, take a look at Requested, Status Action Code, Approved, and Page of. Every one of these are required to be taken care of with utmost precision.

Step number 3 of filling in applicable

Always be very mindful while completing Requested and Status Action Code, since this is the part in which most users make errors.

4. The next part will require your attention in the following areas: Use Form FA for Outpatient, No Yes, and Is the service you are requesting. Always enter all needed information to go onward.

applicable conclusion process clarified (stage 4)

5. The pdf needs to be concluded by dealing with this segment. Further you can see a full list of fields that need accurate information to allow your document usage to be accomplished: Is the service you are requesting, and Approved Through Denied Through.

Stage no. 5 of filling out applicable

Step 3: After you have looked once again at the information in the file's blanks, click on "Done" to complete your form at FormsPal. Get hold of the eligibility after you sign up at FormsPal for a 7-day free trial. Immediately access the pdf form in your FormsPal account, together with any modifications and changes conveniently saved! FormsPal guarantees risk-free document editing devoid of data record-keeping or sharing. Rest assured that your details are in good hands here!

Nevada Form Fa 6 isn’t the one you’re looking for?

Related Documents