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This version of the form is not currently in use and is provided for reference only. Download this version of
Form FA-94
for the current year.
Form FA-94 Physician Certification of Terminal Illness - Nevada Medicaid Hospice Program - Nevada
What Is Form FA-94?
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-94?A: Form FA-94 is the Physician Certification of Terminal Illness for the Nevada Medicaid Hospice Program.
Q: What is the purpose of Form FA-94?A: The purpose of Form FA-94 is to certify that a patient has a terminal illness and is eligible for the Nevada Medicaid Hospice Program.
Q: Who can complete Form FA-94?A: The form must be completed by a physician who is caring for the patient and is familiar with their medical condition.
Q: What information is required on Form FA-94?A: Form FA-94 requires the physician to provide details about the patient's terminal illness, prognosis, and anticipated life expectancy.
Q: Is there a deadline for submitting Form FA-94?A: There is no specific deadline for submitting Form FA-94, but it is recommended to do so as soon as the patient meets the criteria for hospice care.
Form Details:
- Released on April 3, 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;
- Fill out the form in our online filing application.
Download a fillable version of Form FA-94 by clicking the link below{class="scroll_to"} or browse more documents and templates provided by the Nevada Department of Health and Human Services.
Download Form FA-94 Physician Certification of Terminal Illness - Nevada Medicaid Hospice Program - Nevada
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