Form NMO-4 "Recipient Request Pharmacy Lock-In Change" - Nevada

What Is Form NMO-4?

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.

Form Details:

  • Released on February 1, 2019;
  • 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 NMO-4 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form NMO-4 "Recipient Request Pharmacy Lock-In Change" - Nevada

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Division of Health Care Financing and Policy
1100 East William Street, Suite 101
Carson City, Nevada 89701
(775) 684-3600
Recipient Request Pharmacy Lock-In Change
Recipient Name (
__________________________________ Medicaid ID: _____________________
Please Print)
Current Locked-In Pharmacy
Recipient’s Choice
Pharmacy Assigned by Medicaid
Current Locked-in Pharmacy ________________________________________________________________________
Pharmacy Address ________________________________________________________________________________
City __________________________________________ State _____________________________________________
District Office Staff Only
(Complete entire form before faxing)
Current Pharmacy Phone Number: _________________ Current Pharmacy Fax Number _________________________
Date Faxed to Current Pharmacy ___________________ Requested Effective Date _____________________________
(Maintain Fax confirmation receipt)
New Locked-in Pharmacy
New Locked-in Pharmacy __________________________________________________________________________
Pharmacy Address ________________________________________________________________________________
City ___________________________________________ State ____________________________________________
Reason for Change: ________________________________________________________________________________
_________________________________________________________________________________________________
Recipient Signature _______________________________________________Date _____________________________
District Office Staff Only (
Complete entire form before faxing)
Change Initiated by Recipient
Change Initiated by Pharmacy
New Pharmacy Phone Number: __________________ New Pharmacy Fax Number _____________________________
Date Faxed to New Pharmacy _____________________ Requested Effective Date _____________________________
(Maintain FAX confirmation receipt)
Medicaid D.O. Staff Name _________________________________________Phone No. ________________________
Date Faxed to SUR____________________________
(Maintain FAX confirmation receipt)
Please return form to the District Office Health Care Coordinators for submittal
Carson City District Office
Las Vegas District Office
Elko District Office
Reno District Office
1100 E. William Street, Suite 102
1210 S. Valley View, Suite 104
1010 Ruby Vista Drive, Suite 103
745 W. Moana Lane, Suite 200
Carson City, NV 89701
Las Vegas, NV 89102
Elko, NV 89801
Reno, NV 89509
Telephone: (775) 684-3651
Telephone: (702) 668-4200
Telephone: (775) 753-1191
Telephone: (775) 687-1900
Fax: (775) 684-3663
Fax: (702) 668-4280
Fax: (775) 753-1101
Fax: (775) 687-1901
Distribution of Copies to: OptumRx., Medicaid District Office, Program Services Pharmacy Specialist, Surveillance and Utilization Review,
Medicaid Hearings Unit, Pharmacy, Physician(s)
NMO-4 (02/19)
Division of Health Care Financing and Policy
1100 East William Street, Suite 101
Carson City, Nevada 89701
(775) 684-3600
Recipient Request Pharmacy Lock-In Change
Recipient Name (
__________________________________ Medicaid ID: _____________________
Please Print)
Current Locked-In Pharmacy
Recipient’s Choice
Pharmacy Assigned by Medicaid
Current Locked-in Pharmacy ________________________________________________________________________
Pharmacy Address ________________________________________________________________________________
City __________________________________________ State _____________________________________________
District Office Staff Only
(Complete entire form before faxing)
Current Pharmacy Phone Number: _________________ Current Pharmacy Fax Number _________________________
Date Faxed to Current Pharmacy ___________________ Requested Effective Date _____________________________
(Maintain Fax confirmation receipt)
New Locked-in Pharmacy
New Locked-in Pharmacy __________________________________________________________________________
Pharmacy Address ________________________________________________________________________________
City ___________________________________________ State ____________________________________________
Reason for Change: ________________________________________________________________________________
_________________________________________________________________________________________________
Recipient Signature _______________________________________________Date _____________________________
District Office Staff Only (
Complete entire form before faxing)
Change Initiated by Recipient
Change Initiated by Pharmacy
New Pharmacy Phone Number: __________________ New Pharmacy Fax Number _____________________________
Date Faxed to New Pharmacy _____________________ Requested Effective Date _____________________________
(Maintain FAX confirmation receipt)
Medicaid D.O. Staff Name _________________________________________Phone No. ________________________
Date Faxed to SUR____________________________
(Maintain FAX confirmation receipt)
Please return form to the District Office Health Care Coordinators for submittal
Carson City District Office
Las Vegas District Office
Elko District Office
Reno District Office
1100 E. William Street, Suite 102
1210 S. Valley View, Suite 104
1010 Ruby Vista Drive, Suite 103
745 W. Moana Lane, Suite 200
Carson City, NV 89701
Las Vegas, NV 89102
Elko, NV 89801
Reno, NV 89509
Telephone: (775) 684-3651
Telephone: (702) 668-4200
Telephone: (775) 753-1191
Telephone: (775) 687-1900
Fax: (775) 684-3663
Fax: (702) 668-4280
Fax: (775) 753-1101
Fax: (775) 687-1901
Distribution of Copies to: OptumRx., Medicaid District Office, Program Services Pharmacy Specialist, Surveillance and Utilization Review,
Medicaid Hearings Unit, Pharmacy, Physician(s)
NMO-4 (02/19)