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.
Q: What is Form FA-69?
A: Form FA-69 is a Prior Authorization Request form for ADHD treatment for recipients under the age of 18 in Nevada.
Q: What is the purpose of Form FA-69?
A: The purpose of Form FA-69 is to request prior authorization for ADHD treatment for recipients under the age of 18 in Nevada.
Q: Who needs to fill out Form FA-69?
A: The form needs to be filled out by the healthcare provider who is requesting prior authorization for ADHD treatment for a recipient under the age of 18 in Nevada.
Q: What information is required on Form FA-69?
A: Form FA-69 requires information such as recipient's name, Medicaid ID, diagnosis, treatment details, and supporting documentation.
Q: What happens after submitting Form FA-69?
A: After submitting Form FA-69, the request will be reviewed by the Nevada Medicaid Prior Authorization Unit, and a decision will be communicated to the healthcare provider.
Q: How long does it take to get a decision after submitting Form FA-69?
A: The timeframe for a decision on Form FA-69 varies, but it is typically within 14 calendar days.
Download a fillable version of Form FA-69 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.