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1. FA-11.pdf
... Rehabilitation) Additional Treatment History (for QMHP use, if needed): SECTION VII. DISCHARGE PLAN AND ESTIMATED DISCHARGE DATE FA-11 Page 3 of 4 Updated 12 ...
2. FA-11B.pdf
... Name Dosage/Frequency 1. 2. 3. 4. 5. SECTION VII. CURRENT FUNCTIONING AND RISK FACTORS Describe functioning in various areas (e.g. ...
3. FA-11E.pdf
... ABA) Authorization Request Recipient Name: _____ Date of Request: _____ VII. Review of Services Provided Over the Previously Authorized Period (Provider will report ...
4. FA-11E-I.pdf
... additional space is needed, attach additional pages of 3-4 from the FA-11E form. VII. Review of Services Provided Over the Previously Authorized Period • For ...
5. FA-11D.pdf
... Behavioral Health Authorization Request Recipient Name: _____ Date of Request: _____ VII. COMORBID DISORDERS (Include psychiatric and physical) Quadrant of Care Category I-IV ...
6. FA-29A.pdf
... provider. HCPCS/CPT/CDT Code Description End date for each service SECTION VII: ADDITIONAL DETAILS Additional comments or contact information not specified above that would assist ...
7. FA-15.pdf
... what were the denial reasons? Describe outcome of in-state referrals and denial reasons. VII. REQUESTED DATES AND SERVICES Requested Admission Date: Number of Days Requested: ...
8. FA-30.pdf
... : _____ Social Security # if Medicaid ID is Unknown: _____ SECTION VII: OUT-OF-STATE NURSING FACILITY PLACEMENT TRACKING Providers must notify Nevada Medicaid when recipients are ...
9. FA-12.pdf
... : If applicable, list the most recent lab levels for the above medications: VII. REQUESTED TREATMENT Requested Treatment: SA Rehabilitation Detoxification Inpatient Psychiatric Are you requesting ...
10. FA-1B.pdf
... request is not for a seating system(s ) .( Skip to Section VII.) Updated 04/24/2025 FA-1B Page 9 of 14 ( ...
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