Form NMO-3733 "Residential Treatment Center (Rtc) Medicaid Policy Compliance Form" - Nevada

What Is Form NMO-3733?

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 1, 2012;
  • 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 NMO-3733 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 NMO-3733 "Residential Treatment Center (Rtc) Medicaid Policy Compliance Form" - Nevada

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State of Nevada
Division of Health Care Financing and Policy
Residential Treatment Center (RTC) Medicaid Policy Compliance Form
The Division of Health Care Financing and Policy (DHCFP) requests verification of compliance with the following
requirements for providing behavioral health treatment at _______________________________, a RTC located at
_________________________________________________________________________________________________
RESIDENTIAL TREATMENT CENTER INFORMATION
Facility Name:
Address:
Telephone number:
Fax number:
E-Mail:
Contact Person:
Please initial in box to indicate compliance with requirement, and/or provide dates and authorized signature where
requested.
Requirements
Initials
Currently Accredited by:
Joint Commission
Commission on Accreditation of Rehabilitation Facilities (CARF)
Council on Accreditation of Services for Families and Children (COA)
Licensed as a Residential Treatment Facility within the State the facility operates.
Name_____________________________________ Lic. No. ________________________
Facility is operated in accordance with current Medicaid Services Manual (MSM) Chapter 400 Section
403.8 (revised as of _____/______/_______).
Letter of Attestation on file with the State of Nevada confirming the facility is in compliance with Centers
for Medicare and Medicaid Services (CMS) standards governing the use of restraint and seclusion (42CFR,
Part 483, Subpart G).
Date of Letter: _______/_______/_________
Signing Authority: (Print Name)___________________________________________________________
Quality Assurance (QA)/Quality Improvement program in place.
Facility has a process to submit an annual QA report to the DHCFP upon request.
Facility is compliant with Quarterly Family Visits policy outlined in MSM 403.8B.6.
Notification of Critical Events (Incident Reports or Sentinel Events) is consistent with timeframes specified
in MSM 403.8B.2.
Facility
has
understanding
of
services
and
medications
included
in
per
diem
rate
MSM 403.8A(1).
Further provider information regarding Nevada Medicaid RTC policy can be found in the MSM Chapter 400, Section
403.8 available at: https://dhcfp.nv.gov/index/htm.
By signing this form, authorized person (i.e., facility director, CEO, or administrator) is confirming that
_________________________________________________________________________________ is in compliance
with MSM policies relevant to enrollment in Nevada Medicaid for providing RTC services for the State of Nevada.
________________________________________
_____________________________________
Signature
Title
__________________________________
Date
NMO-3733 (10/12)
State of Nevada
Division of Health Care Financing and Policy
Residential Treatment Center (RTC) Medicaid Policy Compliance Form
The Division of Health Care Financing and Policy (DHCFP) requests verification of compliance with the following
requirements for providing behavioral health treatment at _______________________________, a RTC located at
_________________________________________________________________________________________________
RESIDENTIAL TREATMENT CENTER INFORMATION
Facility Name:
Address:
Telephone number:
Fax number:
E-Mail:
Contact Person:
Please initial in box to indicate compliance with requirement, and/or provide dates and authorized signature where
requested.
Requirements
Initials
Currently Accredited by:
Joint Commission
Commission on Accreditation of Rehabilitation Facilities (CARF)
Council on Accreditation of Services for Families and Children (COA)
Licensed as a Residential Treatment Facility within the State the facility operates.
Name_____________________________________ Lic. No. ________________________
Facility is operated in accordance with current Medicaid Services Manual (MSM) Chapter 400 Section
403.8 (revised as of _____/______/_______).
Letter of Attestation on file with the State of Nevada confirming the facility is in compliance with Centers
for Medicare and Medicaid Services (CMS) standards governing the use of restraint and seclusion (42CFR,
Part 483, Subpart G).
Date of Letter: _______/_______/_________
Signing Authority: (Print Name)___________________________________________________________
Quality Assurance (QA)/Quality Improvement program in place.
Facility has a process to submit an annual QA report to the DHCFP upon request.
Facility is compliant with Quarterly Family Visits policy outlined in MSM 403.8B.6.
Notification of Critical Events (Incident Reports or Sentinel Events) is consistent with timeframes specified
in MSM 403.8B.2.
Facility
has
understanding
of
services
and
medications
included
in
per
diem
rate
MSM 403.8A(1).
Further provider information regarding Nevada Medicaid RTC policy can be found in the MSM Chapter 400, Section
403.8 available at: https://dhcfp.nv.gov/index/htm.
By signing this form, authorized person (i.e., facility director, CEO, or administrator) is confirming that
_________________________________________________________________________________ is in compliance
with MSM policies relevant to enrollment in Nevada Medicaid for providing RTC services for the State of Nevada.
________________________________________
_____________________________________
Signature
Title
__________________________________
Date
NMO-3733 (10/12)