Nevada Department of Health and Human Services Forms

This Form is used for FQHC and RHC providers in Nevada to submit a claim for supplemental payments through the Wrap Supplemental Payment Program.

This form is used for the Certification of Governmental Entity Participation in the Medicaid Supplemental Payment Program in Nevada.

This form is used for hospitals in Nevada to certify their participation in the Medicaid Supplemental Payment Program. It ensures that hospitals receive supplemental payments for eligible Medicaid services provided.

This form is used for low-income individuals and needy care providers in the state of Nevada to enter into a collaboration agreement.

This Form is used for providing operational information about service centers in Nevada.

This form is used for service center authorization for healthcare providers in Nevada.

This form is used for registering for Payerpath in the state of Nevada.

This document is used for conducting a Level of Care Assessment for Nursing Facilities in Nevada. It provides instructions on how to complete the Form FA-19.

This Form is used for establishing an Electronic Funds Transfer Agreement in the state of Nevada. It outlines the terms and conditions for electronically transferring funds between financial institutions.

This Form is used for facilitating the placement of individuals in out-of-state nursing facilities in Nevada.

This Form is used for providers in Nevada to update their information with the state.

This form is used for submitting an affidavit related to a rape in Nevada in order to request an abortion.

This form is used for Nevada Medicaid recipients who are undergoing a hysterectomy to acknowledge their understanding of the procedure and its potential risks.

This Form is used for individuals in Nevada to apply for revalidation as a healthcare provider.

This form is used for declaring an abortion under the circumstance of rape in the state of Nevada. It is a legal document that allows individuals to report and certify the occurrence of rape in relation to an abortion.

This form is used for declaring an abortion due to incest in the state of Nevada.

This form is used for submitting an abortion affidavit in cases of incest in the state of Nevada.

This Form is used for individuals who want to enroll as a provider in Nevada. It is the initial enrollment application for providers.

This form is used for provider enrollment applications for ordering, prescribing or referring (OPR) providers in the state of Nevada.

This Form is used for requesting prior authorization for the medication Actemra (Tocilizumab) in the state of Nevada.

This form is used for groups and facilities in Nevada to apply for revalidation as a provider.

This form is used for requesting prior authorization for non-preferred drugs in Nevada.

This Form is used for providers in Nevada to apply for initial enrollment in a group or facility.

This Form is used for requesting prior authorization for Cox-II inhibitors in the state of Nevada.

This Form is used for requesting prior authorization for the medication Amevive (Alefacept) in the state of Nevada.

This form is used for requesting prior authorization for ADHD treatment for recipients aged 18 and above in Nevada.

This Form is used for requesting prior authorization for growth hormone treatment for recipients under the age of 21 in Nevada.