Forms
Nevada Medicaid Forms Can Now Be Submitted Using the Provider Web Portal
On July 6, 2015, Nevada Medicaid completed updating all of the Nevada Medicaid forms that are available on this website. These forms have been updated to a format that allows them to be completed, downloaded and saved electronically. In addition, an enhancement has been made to allow some forms to be submitted online using the “Upload Files” page on the Provider Web Portal.
Please see Web Announcement 938 for the list of forms that can be uploaded using the “Upload Files” page on the Provider Web Portal, the types of forms that may not be uploaded, and screenshots and instructions for uploading forms. Upload instructions are also available in the new Electronic Verification System (EVS) User Manual Chapter 8.
Prior Authorization Forms
All prior authorization forms are for completion and submission by current Medicaid providers only.
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 |
|---|---|
| FA-34 | Provider Voluntary Termination Notice |
Sterilization/Abortion Forms
Sterilization/Abortion forms are for completion and submission by current Medicaid providers only.
Appeals Forms
Appeals forms are for completion and submission by current Medicaid providers only.
| Form Number | Title |
|---|---|
| FA-90 | Formal Claim Appeal Request |
Hospice Forms
The following forms are for the use of Nevada Medicaid Hospice providers.
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 |
|---|---|
| FA-100 | Initial Emergency Dialysis Case Certification |
| FA-101 | Monthly Emergency Dialysis Case Certification |
Medicaid Attestation Form
The following form is for the use of Nevada Medicaid providers to attest the appropriateness of Qualified Clinical Trials in which the recipient is participating.
| Form Number | Title |
|---|---|
| FA-110 | Attestation Form on the Appropriateness of the Qualified Clinical Trial |
Additional Doula Services Certification Form
The following form is for the use of Nevada Medicaid providers to certify the recipient has received prenatal/antepartum and/or oral health care visits during the current pregnancy.
| Form Number | Title |
|---|---|
| FA-111 | Certification for Additional Doula Services |
Nevada DHCFP Forms
The following forms are for the use of Nevada Medicaid and Nevada Check Up providers.
| Form Number | Title |
|---|---|
| NMO-7073 | Functional Assessment Service Plan |
| NMO-7073 Instructions | Functional Assessment Service Plan Instructions |
| NMO-7073 (SP) | Functional Assessment Service Plan (Spanish) |
| NMO-7073 Instructions (SP) | Functional Assessment Service Plan Instructions (Spanish) |
| NMO-3430A | Nevada DHCFP Serious Occurrence Report |
| NMO-3430A Instructions | Nevada DHCFP Serious Occurrence Report Instructions |
| SOR | Nevada DHCFP Serious Occurrence Report (Web-based Version) |
| SOR Instructions | Nevada DHCFP Serious Occurrence Report Instructions (Web-based Version) |