PDF
Word
Form FA-192 Qutenza (Capsaicin) Prior Authorization Request Form - Nevada
What Is Form FA-192?
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-192?A: Form FA-192 is the Qutenza (Capsaicin) Prior Authorization Request Form for Nevada.
Q: What is Qutenza (Capsaicin)?A: Qutenza (Capsaicin) is a prescription medication used to treat certain types of nerve pain.
Q: Why is a prior authorization request required?A: A prior authorization request is required in order to obtain coverage for Qutenza (Capsaicin) through your insurance plan.
Q: What information is needed on Form FA-192?A: Form FA-192 requires information such as patient details, diagnosis, medication history, and healthcare provider information.
Q: Who should I contact for more information?A: For more information, you should contact your healthcare provider or your insurance company.
Form Details:
- Released on July 6, 2021;
- 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 printable version of Form FA-192 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.
