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-76?
A: Form FA-76 is a Prior Authorization Request form.
Q: What is Cimzia?
A: Cimzia is a medication that contains Certolizumab Pegol.
Q: What is Certolizumab Pegol?
A: Certolizumab Pegol is the active ingredient in Cimzia.
Q: What is a Prior Authorization Request?
A: A Prior Authorization Request is a form used to request approval from the insurance company for coverage of a specific medication or treatment.
Q: Why would I need to fill out Form FA-76?
A: You would need to fill out Form FA-76 if you are seeking prior authorization for Cimzia in Nevada.
Q: Who should fill out Form FA-76?
A: Form FA-76 should be filled out by the prescribing healthcare provider or their authorized representative.
Q: Is there a fee associated with Form FA-76?
A: No, there is no fee associated with filling out Form FA-76.
Download a fillable version of Form FA-76 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.