Form FA-30 Out-Of-State Nursing Facility Placement Packet - Nevada

Form FA-30 or the "Out-of-state Nursing Facility Placement Packet" is a form issued by the Nevada Department of Health and Human Services.

The form was last revised in July 10, 2017 and is available for digital filing. Download an up-to-date Form FA-30 in PDF-format down below or look it up on the Nevada Department of Health and Human Services Forms website.

Step-by-step Form 30 instructions can be downloaded by clicking this link.

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Nevada Medicaid and Nevada Check Up
Out-of-State Nursing Facility Placement Packet
Complete the following information and fax the completed Out-of-State Nursing Facility Placement Packet with all
supporting documents to the Division of Health Care Financing and Policy (DHCFP) Long Term Services and
Supports Nevada Medicaid Out-of-State Coordinator.
Fax this request to: (775) 687-8724
For questions regarding this form, call: (775) 684-3619
DATE OF REQUEST:
______ /______ /________
SECTION I: RECIPIENT INFORMATION
Recipient Name: (last, first, MI)
Male
Female
Date of Birth:
Age:
Marital Status:
M
W
D
S
Recipient Medicaid ID:
Social Security # if Medicaid ID is Unknown:
Guardian Name (or responsible person) if applicable:
Guardian (or responsible person) Telephone Number:
Guardian (or responsible person) Address:
Please indicate if guardianship has been applied for:
Yes
No
Not applicable
Recipient’s living arrangements prior to admit (e.g., group home, parents, ICF/IID, SNF, etc):
SECTION II: CLINICAL INFORMATION
Is this a request for ICF/IID?
Yes
No If Yes, ICF/IID OOS placement requires a Physician Order.
Diagnoses (attach H&P and Physician Progress Notes)
Medications (attach medication record including PRN medications)
Psychosocial Narrative, Behavioral Tracking/Monitoring Records (if OOS placement due to behaviors)
Nursing Progress Notes (attach if describes behaviors making OOS placement needed)
Case Management/Social Worker Discharge Planning Notes
Reason for seeking out-of-state placement (this section must be complete; more than one box can be
checked)
Exit Seeking/Flight Risk Behavior
Wandering Behavior
Violent Behavior
Danger to Self
Danger to Others
Other Inappropriate Behaviors
Requires a Locked Facility
No Appropriate Beds Available In-State
Requires Specialty Care (Bariatric, Pediatric, etc.)
Recipient is unable to return to their prior living situation
Previous facility refusing readmission
Please attach documentation to support any checked items above if not included in the attached clinical
information.
List of all Nevada facilities contacted, date, contact person and reason for denial (attach)
SECTION III: SERVICING PROVIDER INFORMATION
Current Provider Name and Unit:
Telephone Number:
Fax Number:
Admit Date:
Name of Case Manager:
Contact Number:
FA-30
Page 1 of 4
07/10/2017
Nevada Medicaid and Nevada Check Up
Out-of-State Nursing Facility Placement Packet
Complete the following information and fax the completed Out-of-State Nursing Facility Placement Packet with all
supporting documents to the Division of Health Care Financing and Policy (DHCFP) Long Term Services and
Supports Nevada Medicaid Out-of-State Coordinator.
Fax this request to: (775) 687-8724
For questions regarding this form, call: (775) 684-3619
DATE OF REQUEST:
______ /______ /________
SECTION I: RECIPIENT INFORMATION
Recipient Name: (last, first, MI)
Male
Female
Date of Birth:
Age:
Marital Status:
M
W
D
S
Recipient Medicaid ID:
Social Security # if Medicaid ID is Unknown:
Guardian Name (or responsible person) if applicable:
Guardian (or responsible person) Telephone Number:
Guardian (or responsible person) Address:
Please indicate if guardianship has been applied for:
Yes
No
Not applicable
Recipient’s living arrangements prior to admit (e.g., group home, parents, ICF/IID, SNF, etc):
SECTION II: CLINICAL INFORMATION
Is this a request for ICF/IID?
Yes
No If Yes, ICF/IID OOS placement requires a Physician Order.
Diagnoses (attach H&P and Physician Progress Notes)
Medications (attach medication record including PRN medications)
Psychosocial Narrative, Behavioral Tracking/Monitoring Records (if OOS placement due to behaviors)
Nursing Progress Notes (attach if describes behaviors making OOS placement needed)
Case Management/Social Worker Discharge Planning Notes
Reason for seeking out-of-state placement (this section must be complete; more than one box can be
checked)
Exit Seeking/Flight Risk Behavior
Wandering Behavior
Violent Behavior
Danger to Self
Danger to Others
Other Inappropriate Behaviors
Requires a Locked Facility
No Appropriate Beds Available In-State
Requires Specialty Care (Bariatric, Pediatric, etc.)
Recipient is unable to return to their prior living situation
Previous facility refusing readmission
Please attach documentation to support any checked items above if not included in the attached clinical
information.
List of all Nevada facilities contacted, date, contact person and reason for denial (attach)
SECTION III: SERVICING PROVIDER INFORMATION
Current Provider Name and Unit:
Telephone Number:
Fax Number:
Admit Date:
Name of Case Manager:
Contact Number:
FA-30
Page 1 of 4
07/10/2017
Nevada Medicaid and Nevada Check Up
Out-of-State Nursing Facility Placement Packet
Recipient Name: (last, first, MI):______________________________________________________________
Recipient Medicaid ID:_________________ Social Security # if Medicaid ID is Unknown:________________
PASRR screening request submitted:
Yes
No
If the response is Yes, enter date the request was submitted: ______________
Level of Care (LOC) request submitted:
Yes
No
If the response is Yes, enter date the request was submitted: ______________
Medicaid eligibility verified by EVS:
Yes
No
Name of person completing this form (please print):
Title of person completing this form:
Telephone number of person completing this form:
Signature of person completing this form:
Date:
FA-30
Page 2 of 4
07/10/2017
Nevada Medicaid and Nevada Check Up
Out-of-State Nursing Facility Placement Packet
Recipient Name: (last, first, MI):_____________________________________________________________
Recipient Medicaid ID:_________________ Social Security # if Medicaid ID is Unknown:________________
SECTION IV: OUT-OF-STATE NURSING FACILITY PLACEMENT RECIPIENT
ACKNOWLEDGEMENT AND CONSENT
Admission has been denied by all Nevada nursing facilities that could meet my medical requirements;
therefore, I recognize Out-of-State Nursing Facility placement is necessary.
Recipient, Legal Representative or Guardian must print:
I_________________________________________________ give my consent for Out-of-State Nursing
Facility Placement.
Recipient, Legal Representative or Guardian must sign:
Date:
Signature:
Date:
Witnessed by:
SECTION V: OUT-OF-STATE FUNERAL BURIAL RECIPIENT ACKNOWLEDGEMENT
I understand that no Medicaid benefits are payable after death, and Medicaid cannot be responsible for funeral
or burial costs including the return of a deceased’s remains to Nevada.
The recipient has a Burial Plan:
Yes
No
Name of Burial Plan Company: __________________________________________
Plan ID Number: ____________________ Company’s Phone Number: ____________________
If there is no plan, burial assistance from the county of origin may be available and can be applied for at the
time of death.
Signature of Recipient, Legal Representative or Guardian:
Date:
Printed Name and Relationship (if the above is not the recipient):
Name:
Relationship:
SECTION VI: FOR DHCFP USE ONLY
This request for Out-of-State Placement has been:
Approved
Denied
If request is denied, reason for denial:
Reviewer Name (please print):
Reviewer Signature:
Date Reviewed:
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-30
Page 3 of 4
07/10/2017
Nevada Medicaid and Nevada Check Up
Out-of-State Nursing Facility Placement Packet
Recipient Name: (last, first, MI):_____________________________________________________________
Recipient Medicaid ID:_________________ Social Security # if Medicaid ID is Unknown:________________
SECTION VII: OUT-OF-STATE NURSING FACILITY PLACEMENT TRACKING
Providers must notify DHCFP when recipients are placed in an Out-of-State Nursing Facility.
Please complete and fax this page to DHCFP at (775) 687-8724 or call DCHFP at (775) 684-3619.
Name of Out-of-State Nursing Facility where recipient has been placed:
Date recipient was discharged to the above named Out-of-State Nursing Facility:
Name of person completing this form (please print):
Title of person completing this form:
Telephone number of person completing this form:
Signature of person completing this form:
Date:
FA-30
Page 4 of 4
07/10/2017

Download Form FA-30 Out-Of-State Nursing Facility Placement Packet - Nevada

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