Form FA-13A "Rtc Absence Form" - Nevada

What Is Form FA-13A?

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 April 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-13A 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-13A "Rtc Absence Form" - Nevada

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Nevada Medicaid and Nevada Check Up
RTC Absence Form
Purpose: To notify Nevada Medicaid of an absence from a Residential Treatment Center (RTC) . This form
is not to be used for an elopement. The Prior Authorization Data Corrrection Form (FA-29) is to be used to
report an elopement.
Policy for therapeutic pass: A therapeutic home pass must be used 1) to facilitate a recipient’s discharge
back to their home or less restrictive setting, 2) within 90 days of the recipient’s planned discharge and 3) in
coordination with their discharge plan. The recipient must 1) have demonstrated a series of successful
incremental day passes first and 2) be in the final phase of treatment in the RTC program (MSM 403.8A.6a.2).
Limitations: Three therapeutic home passes are allowed per calendar year (MSM 403.8A.6).
Notification/Request Timeline:
This form must be received at least 14 days prior to the pass being issued to the recipient if related to
a therapeutic pass.
This form must be submitted the day of the absence for any other type of absence.
Upload this request through the Provider Web Portal.
Questions? Call: (800) 525-2395
Request Type (please check one):
Notification of a recipient’s 72-hour or less therapeutic home pass
Prior authorization request for a therapeutic home pass longer than 72 hours
Other type of absence, provide details in “Notes” field below
NOTES:
RECIPIENT INFORMATION
Recipient Name:
Recipient ID:
FACILITY INFORMATION
Facility Name:
Facility Address:
NPI:
ABSENCE INFORMATION
Dates of Leave – From:
To:
Time:
Time:
Explain the goals and objectives for a therapeutic home pass and identify how they pertain to the
recipient’s discharge plan or details related to the reason for any other type of leave.
PHYSICIAN’S ORDER
Is it clinically appropriate for the recipient to travel alone?
Yes
No
Is there an escort?
Yes
No
I certify that the individual indicated above meets the requirements for therapeutic home leave if applicable.
Physician Signature: ______________________________________ Date: _________________
Physician Name (print/type): ________________________________________________________
Professional Title: ________________________________________________________________
FA-13A
Page 1 of 1
Updated 04/29/2019 (pv01/30/2019)
Nevada Medicaid and Nevada Check Up
RTC Absence Form
Purpose: To notify Nevada Medicaid of an absence from a Residential Treatment Center (RTC) . This form
is not to be used for an elopement. The Prior Authorization Data Corrrection Form (FA-29) is to be used to
report an elopement.
Policy for therapeutic pass: A therapeutic home pass must be used 1) to facilitate a recipient’s discharge
back to their home or less restrictive setting, 2) within 90 days of the recipient’s planned discharge and 3) in
coordination with their discharge plan. The recipient must 1) have demonstrated a series of successful
incremental day passes first and 2) be in the final phase of treatment in the RTC program (MSM 403.8A.6a.2).
Limitations: Three therapeutic home passes are allowed per calendar year (MSM 403.8A.6).
Notification/Request Timeline:
This form must be received at least 14 days prior to the pass being issued to the recipient if related to
a therapeutic pass.
This form must be submitted the day of the absence for any other type of absence.
Upload this request through the Provider Web Portal.
Questions? Call: (800) 525-2395
Request Type (please check one):
Notification of a recipient’s 72-hour or less therapeutic home pass
Prior authorization request for a therapeutic home pass longer than 72 hours
Other type of absence, provide details in “Notes” field below
NOTES:
RECIPIENT INFORMATION
Recipient Name:
Recipient ID:
FACILITY INFORMATION
Facility Name:
Facility Address:
NPI:
ABSENCE INFORMATION
Dates of Leave – From:
To:
Time:
Time:
Explain the goals and objectives for a therapeutic home pass and identify how they pertain to the
recipient’s discharge plan or details related to the reason for any other type of leave.
PHYSICIAN’S ORDER
Is it clinically appropriate for the recipient to travel alone?
Yes
No
Is there an escort?
Yes
No
I certify that the individual indicated above meets the requirements for therapeutic home leave if applicable.
Physician Signature: ______________________________________ Date: _________________
Physician Name (print/type): ________________________________________________________
Professional Title: ________________________________________________________________
FA-13A
Page 1 of 1
Updated 04/29/2019 (pv01/30/2019)