Form FA-1D "Wheelchair Repair Form" - Nevada

What Is Form FA-1D?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 27, 2021;
  • The latest edition provided by the Nevada Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FA-1D by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form FA-1D "Wheelchair Repair Form" - Nevada

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Nevada Medicaid and Nevada Check Up
Wheelchair Repair Form
Upload this form with the FA-1 (Durable Medical Equipment Prior Authorization Request) through the Provider
Web Portal.
Medical documentation by the prescribing practitioner must be submitted to support that the recipient has ongoing
medical necessity for the item needing repair. This Wheelchair Repair Form must be filled out completely or it and
the prior authorization request will be pended for more information and/or denied. The unaltered complete order
form specific to the manufacturer and the model of the items being requested must be attached. A manufacturer’s
invoice for any replacement parts may be required to substantiate payment by Medicaid. DME providers are
required to educate the recipients on the proper use of durable medical equipment. Per Nevada Medicaid policy,
intentional utilization of DME in a manner not prescribed or recommended, such as an excessive form of
transportation, may be reason for denial of equipment replacement.
For questions regarding this form, call: (800) 525-2395
DATE OF REQUEST:
______ /______ /________
NOTES:
RECIPIENT INFORMATION
Recipient Name (Last, First, MI):
Recipient Medicaid ID:
Date of Birth:
Phone:
PROVIDER INFORMATION
Name of DME company:
NPI:
Fax:
Phone:
WHEELCHAIR INFORMATION
1. Make:________________________ Model:___________________ Serial #:______________________
2. Hour reading #:____________ Age of Equipment in months:_____ Initial Dispense Date:_____________
3. Name of person/company/entity who purchased wheelchair_____________________________________
If Nevada Medicaid did not purchase the wheelchair, the recipient must meet current qualifications for the
item. Any assessment(s) necessary to support medical necessity must have been completed within six
months of the date of request.
4. Is the wheelchair within Manufacturer’s Warranty?
Yes
No
Please submit a copy of the warranty information.
5. Name of manufacturer of replacement parts: ________________________________________________
6. What was the initial complaint from the recipient that prompted the repair evaluation?
FA-1D
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10/27/2021 (pv 01/29/2019)
Nevada Medicaid and Nevada Check Up
Wheelchair Repair Form
Upload this form with the FA-1 (Durable Medical Equipment Prior Authorization Request) through the Provider
Web Portal.
Medical documentation by the prescribing practitioner must be submitted to support that the recipient has ongoing
medical necessity for the item needing repair. This Wheelchair Repair Form must be filled out completely or it and
the prior authorization request will be pended for more information and/or denied. The unaltered complete order
form specific to the manufacturer and the model of the items being requested must be attached. A manufacturer’s
invoice for any replacement parts may be required to substantiate payment by Medicaid. DME providers are
required to educate the recipients on the proper use of durable medical equipment. Per Nevada Medicaid policy,
intentional utilization of DME in a manner not prescribed or recommended, such as an excessive form of
transportation, may be reason for denial of equipment replacement.
For questions regarding this form, call: (800) 525-2395
DATE OF REQUEST:
______ /______ /________
NOTES:
RECIPIENT INFORMATION
Recipient Name (Last, First, MI):
Recipient Medicaid ID:
Date of Birth:
Phone:
PROVIDER INFORMATION
Name of DME company:
NPI:
Fax:
Phone:
WHEELCHAIR INFORMATION
1. Make:________________________ Model:___________________ Serial #:______________________
2. Hour reading #:____________ Age of Equipment in months:_____ Initial Dispense Date:_____________
3. Name of person/company/entity who purchased wheelchair_____________________________________
If Nevada Medicaid did not purchase the wheelchair, the recipient must meet current qualifications for the
item. Any assessment(s) necessary to support medical necessity must have been completed within six
months of the date of request.
4. Is the wheelchair within Manufacturer’s Warranty?
Yes
No
Please submit a copy of the warranty information.
5. Name of manufacturer of replacement parts: ________________________________________________
6. What was the initial complaint from the recipient that prompted the repair evaluation?
FA-1D
Page 1 of 2
10/27/2021 (pv 01/29/2019)
Nevada Medicaid and Nevada Check Up
Wheelchair Repair Form
7. How did the wheelchair come into disrepair? (If normal wear and tear please explain in complete detail the
normal daily/weekly schedule of recipient’s use of this equipment.)
8. Please provide the service repair documentation from the technician describing the steps taken to
determine need and what was found during the wheelchair evaluation. Include previous repairs and dates
of service of repairs.
9. Itemize all parts requiring replacement and their cost (include unaltered complete order form specific to the
manufacturer and the model of the items being requested). Estimate the cost of labor.
CERTIFICATION
I HEREBY CERTIFY that by signing and submitting this report that the information may be relied upon for the
accurate determination of need for repairs.
I certify that all submitted data on this form is true and accurate. Knowingly adding incorrect information or
failing to disclose pertinent information is considered fraud and will be treated as such.
TECHNICIAN OR DME PROVIDER:
Signature:_______________________________________________________________________________
Printed Name:_________________________________________ Signature Date:____________________
Phone Number:_________________________________
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-1D
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