Form FA-6 "Outpatient Medical/Surgical" - Nevada

What Is Form FA-6?

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 January 29, 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 FA-6 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 FA-6 "Outpatient Medical/Surgical" - Nevada

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Prior Authorization Request
Nevada Medicaid and Nevada Check Up
Outpatient Medical/Surgical
(Use Form FA-7 for Outpatient Rehabilitation and Therapy Services)
Upload this request through the Provider Web Portal.
For questions regarding this form, call: (800) 525-2395
DATE OF REQUEST: ______ /______ /________
REQUEST TYPE:
Initial
Continued Services
Retrospective*
Unscheduled Revision
*REQUIRED FOR RETROSPECTIVE REVIEWS ONLY
This recipient was determined eligible for Medicaid benefits on: ______ /______ /________
NOTES:
RECIPIENT INFORMATION
Recipient Name (Last, First, MI):
Recipient ID:
DOB:
Address:
Phone:
City:
State:
Zip Code:
Medicare Insurance Information:
Part A
Part B Medicare ID#:
Other Insurance Name:
Other Insurance ID#:
Responsible Party Name (if applicable):
Responsible Party Address:
Phone:
ORDERING PROVIDER INFORMATION
Ordering Provider Name:
NPI:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Contact Name:
SERVICING PROVIDER INFORMATION
Servicing Provider Name:
NPI:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Contact Name:
CLINICAL INFORMATION
(attach additional sheets if necessary)
No. of Units
Code Requested
Description of Service
Requested
1.
2.
3.
FA-6
Page 1 of 2
Updated 01/29/2019 (pv10/01/2011)
Prior Authorization Request
Nevada Medicaid and Nevada Check Up
Outpatient Medical/Surgical
(Use Form FA-7 for Outpatient Rehabilitation and Therapy Services)
Upload this request through the Provider Web Portal.
For questions regarding this form, call: (800) 525-2395
DATE OF REQUEST: ______ /______ /________
REQUEST TYPE:
Initial
Continued Services
Retrospective*
Unscheduled Revision
*REQUIRED FOR RETROSPECTIVE REVIEWS ONLY
This recipient was determined eligible for Medicaid benefits on: ______ /______ /________
NOTES:
RECIPIENT INFORMATION
Recipient Name (Last, First, MI):
Recipient ID:
DOB:
Address:
Phone:
City:
State:
Zip Code:
Medicare Insurance Information:
Part A
Part B Medicare ID#:
Other Insurance Name:
Other Insurance ID#:
Responsible Party Name (if applicable):
Responsible Party Address:
Phone:
ORDERING PROVIDER INFORMATION
Ordering Provider Name:
NPI:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Contact Name:
SERVICING PROVIDER INFORMATION
Servicing Provider Name:
NPI:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Contact Name:
CLINICAL INFORMATION
(attach additional sheets if necessary)
No. of Units
Code Requested
Description of Service
Requested
1.
2.
3.
FA-6
Page 1 of 2
Updated 01/29/2019 (pv10/01/2011)
Prior Authorization Request
Nevada Medicaid and Nevada Check Up
Outpatient Medical/Surgical
(Use Form FA-7 for Outpatient Rehabilitation and Therapy Services)
4.
5
Is the service you are requesting a hospice benefit?
Yes
No
Are you requesting Healthy Kids (EPSDT) referral/services?
Yes
No
Conditions/Symptoms (include ICD-10 codes and descriptions):
Previous Treatment/Services (include dates):
Results of Previous Treatment/Services:
Other Clinical Information (to support medical necessity of the requested services):
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions,
coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is
privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the
employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this
communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.
FA-6
Page 2 of 2
Updated 01/29/2019 (pv10/01/2011)
Page of 2