Form FA-2 "Durable Medical Equipment (Dme) and Vision History Request" - Nevada

What Is Form FA-2?

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 March 10, 2016;
  • 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-2 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-2 "Durable Medical Equipment (Dme) and Vision History Request" - Nevada

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Hewlett Packard Enterprise - Nevada Medicaid and Nevada Check Up
Durable Medical Equipment (DME) and Vision History Request
Online Treatment History Search: DME and vision providers can search recipient treatment history online instead
of using this form.
To access “Treatment History” go to the
Provider Web Portal log-in webpage
at
www.medicaid.nv.gov
and
click on “Treatment History” under the “Claims” tab.
Instructions are available in EVS User Manual Chapter 9: Treatment History. The Manual is located on the
EVS User Manual webpage
at www.medicaid.nv.gov.
Purpose of this form: To determine if the recipient has Durable Medical Equipment (DME) or Vision benefits
available by requesting documentation of a recipient's service history.
Instructions:
 One recipient per form is permitted.
 Allow up to five business days from Hewlett Packard Enterprise receipt for a response.
Email this request to:
nvcodehistory@hpe.com
(Instructions: Save this form to your computer, complete it and
save it again, then attach it to the email. Please send the form using encrypted email*, such as ZixMail®, and write
“FA-2” in the subject line.) If the request is submitted via email, the code history will be returned to you via email.
If the online treatment history search or email submission are not available to you, fax this request to: (775) 335-8594
For questions regarding this form, call: (877) 638-3472 (when calling, press 2, then press 0, then press 2)
Request Date:
Recipient Name:
Recipient ID:
Is this a new patient?
Yes
No
Enter the date the recipient was last seen at your office:
PROVIDER INFORMATION
Name:
NPI:
Fax:
Phone:
Contact Name:
In the white spaces below, enter the procedure code(s) for which you are requesting service history. Leave the right,
shaded columns blank.
Hewlett Packard Enterprise
Hewlett Packard Enterprise
Procedure Code
Procedure Code
USE ONLY:
USE ONLY:
Last Date of Service
Last Date of Service
Disclaimer
 This request for a recipient's DME and Vision service history is not a guarantee of payment. Payment is contingent upon
eligibility and available benefits. It is the responsibility of the provider to check eligibility monthly.
 While the recipient is eligible for Fee For Service (FFS), benefits under FFS are available as described in Medicaid Services
Manual Chapter 1100 and Chapter 1300 subject to all program limitations.
 The information on this form is privileged and confidential.
*
Please remember to encrypt protected health information when using email. Hewlett Packard Enterprise can receive encrypted
email via ZixMail. “Encryption is used to protect the confidentiality of stored data and data that are being transmitted to and from the
secured network via the Internet. Establishing encryption where necessary is a basic step for protecting sensitive data.”
[Department of Health and Human Services, Office of Inspector General, March 2014, A-07-14-00433, High-Risk Security
Vulnerabilities Identified During Reviews Of Information Technology General Controls At State Medicaid Agencies]
FA-2
Page 1 of 1
03/10/2016 (pv12/01/2014)
Hewlett Packard Enterprise - Nevada Medicaid and Nevada Check Up
Durable Medical Equipment (DME) and Vision History Request
Online Treatment History Search: DME and vision providers can search recipient treatment history online instead
of using this form.
To access “Treatment History” go to the
Provider Web Portal log-in webpage
at
www.medicaid.nv.gov
and
click on “Treatment History” under the “Claims” tab.
Instructions are available in EVS User Manual Chapter 9: Treatment History. The Manual is located on the
EVS User Manual webpage
at www.medicaid.nv.gov.
Purpose of this form: To determine if the recipient has Durable Medical Equipment (DME) or Vision benefits
available by requesting documentation of a recipient's service history.
Instructions:
 One recipient per form is permitted.
 Allow up to five business days from Hewlett Packard Enterprise receipt for a response.
Email this request to:
nvcodehistory@hpe.com
(Instructions: Save this form to your computer, complete it and
save it again, then attach it to the email. Please send the form using encrypted email*, such as ZixMail®, and write
“FA-2” in the subject line.) If the request is submitted via email, the code history will be returned to you via email.
If the online treatment history search or email submission are not available to you, fax this request to: (775) 335-8594
For questions regarding this form, call: (877) 638-3472 (when calling, press 2, then press 0, then press 2)
Request Date:
Recipient Name:
Recipient ID:
Is this a new patient?
Yes
No
Enter the date the recipient was last seen at your office:
PROVIDER INFORMATION
Name:
NPI:
Fax:
Phone:
Contact Name:
In the white spaces below, enter the procedure code(s) for which you are requesting service history. Leave the right,
shaded columns blank.
Hewlett Packard Enterprise
Hewlett Packard Enterprise
Procedure Code
Procedure Code
USE ONLY:
USE ONLY:
Last Date of Service
Last Date of Service
Disclaimer
 This request for a recipient's DME and Vision service history is not a guarantee of payment. Payment is contingent upon
eligibility and available benefits. It is the responsibility of the provider to check eligibility monthly.
 While the recipient is eligible for Fee For Service (FFS), benefits under FFS are available as described in Medicaid Services
Manual Chapter 1100 and Chapter 1300 subject to all program limitations.
 The information on this form is privileged and confidential.
*
Please remember to encrypt protected health information when using email. Hewlett Packard Enterprise can receive encrypted
email via ZixMail. “Encryption is used to protect the confidentiality of stored data and data that are being transmitted to and from the
secured network via the Internet. Establishing encryption where necessary is a basic step for protecting sensitive data.”
[Department of Health and Human Services, Office of Inspector General, March 2014, A-07-14-00433, High-Risk Security
Vulnerabilities Identified During Reviews Of Information Technology General Controls At State Medicaid Agencies]
FA-2
Page 1 of 1
03/10/2016 (pv12/01/2014)