Forms

Get Adobe Reader You will need Adobe® Reader to view any printable PDF document(s).
Click the button to the left to download a free copy of Adobe® Reader.
Prior Authorization Forms

All prior authorization forms are for completion and submission by current Medicaid providers only.

Form Number Title
Form Number Title
FA-1 Durable Medical Equipment Prior Authorization Request
FA-1A Usage Evaluation for Continuing Use of BIPAP and CPAP Devices
FA-1B Mobility Assessment and Prior Authorization (PA), Revised 12/29/10
FA-1B Instructions Mobility Assessment and Prior Authorization (PA) Instructions
FA-2 Durable Medical Equipment (DME) and Vision History Request
FA-3 Inpatient Rehabilitation Referral/Assignment
FA-4 Long Term Acute Care Prior Authorization
FA-6 Outpatient Medical/Surgical Services Prior Authorization Request
FA-7 Outpatient Rehabilitation and Therapy Services Prior Authorization Request
FA-8 Inpatient Medical/Surgical Prior Authorization Request
FA-8A Induction of Labor Prior to 39 Weeks and Scheduled Elective C-Sections
FA-10A Psychological Testing
FA-10B Neuropsychological Testing
FA-10C Developmental Testing
FA-10D Neurobehavioral Status Exam
FA-11 Outpatient Mental Health Request
FA-11A Behavioral Health Authorization
FA-11D Substance Abuse/Behavioral Health Authorization Request
FA-12 Inpatient Mental Health Prior Authorization
FA-13 Residential Treatment Center Concurrent Review
FA-13A RTC Therapeutic Home Pass Form
FA-14 Inpatient Mental Health Services Concurrent Review Request
FA-15 Residential Treatment Center Prior Authorization
FA-16 Home Health Agency Prior Authorization Request
FA-17 Adult Day Health Care Services Prior Authorization Request
FA-17 Instructions Adult Day Health Care Services Prior Authorization Request Instructions
FA-18 Level 1 Identification Screening for PASRR
FA-19 Level of Care Assessment for Nursing Facilities
FA-19 Instructions Level of Care Assessment for Nursing Facilities Instructions
FA-20 PASRR and LOC Copy Request
FA-21 PASRR and LOC Data Correction Form
FA-22 Screening Request for Pediatric Specialty Care Services
FA-24 Personal Care Services (PCS) Prior Authorization | PCS Assessment Forms
FA-24 Instructions Personal Care Services (PCS) Prior Authorization Instructions
FA-24A Coordination of Hospice and Waiver or Personal Care Services (PCS)
FA-24A Instructions Coordination of Hospice and Waiver or Personal Care Services (PCS) Instructions
FA-24B Legally Responsible Individual (LRI) Availability Determination for the Personal Care Services Program
FA-25 Handicapping Labiolingual Deviation (HLD) Index Report
FA-26 Client Treatment History Report (For Medicaid Orthodontic Treatment)
FA-26A Dental History Request
FA-27 Hospice Notification Form
FA-28 Hospice Medical Ancillary Information
FA-29 Prior Authorization Data Correction Form

Enrollment Forms

Enrollment forms are for completion and submission only by providers applying for enrollment in the Nevada Medicaid and Nevada Check Up program.

Form Number Title
Form Number Title
FA-31A Provider Re-Enrollment Application Packet (Individuals)
FA-31B Provider Re-Enrollment Application Packet (Groups/Facilities)
FA-31C Provider Initial Enrollment Application Packet (Individuals)
FA-31D Provider Initial Enrollment Application Packet (Groups/Facilities)
--- Medical Supervisor Acknowledgement for Behavioral Health Outpatient Treatment (Provider Type 14)
--- Policy Acknowledgement and Supervisor Information (Provider Types 14 and 82)
FA-32 Electronic Funds Transfer Agreement
FA-33 Provider Information Change Form
FA-34 Written Notice of Provider Termination
FA-35 Electronic Transaction Agreement for Service Centers
FA-36 Service Center Operational Information
FA-37 Service Center Authorization
FA-39 Payerpath Enrollment

Provider Training Forms

Advanced classes, taken in conjunction with new provider training classes are recommended for all new Medicaid providers/staff, and as a yearly review for established providers/staff.

Form Number Title
Form Number Title
FA-41 2014 Training Registration Form
FA-43 Pharmacy Provider Training Registration

Sterilization/Abortion Forms

Sterilization/Abortion forms are for completion and submission by current Medicaid providers only.

Form Number Title
Form Number Title
FA-50 Receipt of Hysterectomy Info Before Surgery
FA-51 Receipt of Hysterectomy Info After Surgery
FA-52 Abortion Affidavit (Rape)
FA-53 Abortion Affidavit (Incest)
FA-54 Abortion Declaration (Rape)
FA-55 Abortion Declaration (Incest)
FA-56 Sterilization Consent

Pharmacy Forms

Pharmacy forms are for completion and submission by current Medicaid providers only.

Form Number Title
Form Number Title
FA-59 Pharmacy Authorization
FA-60 MAC Pricing Appeal Form
FA-61 Actemra® (tocilizumab)
FA-62 Request for Pharmaceutical Product Review
FA-63 PDL Exception Prior Authorization
FA-64 Cox-II Prior Authorization
FA-65 Synagis® Prior Authorization
FA-66 Amevive® (alefacept)
FA-67 Growth Hormones For Recipients Under Age 21 Prior Authorization
FA-68 ADHD Treatment For Recipients Age 18 And Above
FA-69 ADHD Treatment For Recipients Under 18
FA-70 Psychotropic Agents for Children and Adolescents
FA-71 Multiple Sclerosis – Ampyra® Prior Authorization
FA-72 Topical Androgen Agents
FA-73 Suboxone® and Subutex®
FA-74 Makena® (hydroxyprogesterone caproate injection)
FA-75 Hepatitis C Protease Inhibitors
FA-76 Cimzia® (certolizumab pegol)
FA-77 Humira® (adalimumab)
FA-78 Kineret® (anakinra)
FA-79 Orencia® (abatacept)
FA-80 Remicade® (infliximab)
FA-81 Simponi® (golimumab)
FA-82 Stelara® (ustekinumab)
FA-83 Xolair® (omalizumab)
FA-84 Cesamet® (nabilone)
FA-85 Forteo® (teriparatide)
FA-86 Marinol® (dronabinol)
FA-87 Prolia® (denosumab)

Appeals Forms

Appeals forms are for completion and submission by current Medicaid providers only.

Form Number Title
Form Number Title
FA-90 Formal Claim Appeal Request

Emergency Dialysis Case Certification Forms

The following forms are for the use of Nevada Medicaid and Nevada Check Up providers to certify that a non-United States citizen has met the medical conditions to be eligible to receive outpatient emergency End Stage Renal Disease (ESRD) services through the Federal Emergency Services (FES) program.

Form Number Title
Form Number Title
FA-100 Initial Emergency Dialysis Case Certification
FA-101 Monthly Emergency Dialysis Case Certification

Nevada DHCFP Forms

The following forms are for the use of Nevada Medicaid and Nevada Check Up providers.

Form Number Title
Form Number Title
NMO-3430A Nevada DHCFP Serious Occurrence Report
NMO-3430A Instructions Nevada DHCFP Serious Occurrence Report Instructions

On this website and on documents posted herein:

Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes, descriptions and data are copyrighted by the American Medical Association (AMA) and the American Dental Association (ADA), respectively, all rights reserved. AMA and ADA assume no liability for data contained or not contained on this website and on documents posted herein.

CPT is a registered trademark ® of the AMA. CDT is a registered trademark ® of the ADA. Applicable FARS/DFARS apply.

The Nevada Division of Health Care Financing adheres to all applicable privacy policies and standards, including HIPAA rules and regulations, regarding protected health information. Click here to see the State of Nevada Online Privacy Policy

Back to Top