Form FA-76 Prior Authorization Request - Cimzia (Certolizumab Pegol) - Nevada

Form FA-76 Prior Authorization Request - Cimzia (Certolizumab Pegol) - Nevada

What Is Form FA-76?

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.

FAQ

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.

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Form Details:

  • Released on July 28, 2017;
  • 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;

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.

Download Form FA-76 Prior Authorization Request - Cimzia (Certolizumab Pegol) - Nevada

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  • Form FA-76 Prior Authorization Request - Cimzia (Certolizumab Pegol) - Nevada, Page 1
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