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This version of the form is not currently in use and is provided for reference only. Download this version of
Form FA-25
for the current year.
Form FA-25 Orthodontic Medical Necessity (Omn) Form - Nevada
What Is Form FA-25?
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-25?
A: Form FA-25 is the Orthodontic Medical Necessity (OMN) form in Nevada.
Q: What is the purpose of Form FA-25?
A: The purpose of Form FA-25 is to determine the medical necessity of orthodontic treatment.
Q: Who uses Form FA-25?
A: Form FA-25 is used by orthodontists, dentists, and other healthcare professionals in Nevada.
Q: What information does Form FA-25 require?
A: Form FA-25 requires detailed information about the patient's dental and medical history, as well as supporting documentation.
Q: Is Form FA-25 mandatory?
A: Yes, Form FA-25 is mandatory for Medicaid patients in Nevada who are seeking orthodontic treatment.
Q: What happens after submitting Form FA-25?
A: After submitting Form FA-25, it will be reviewed by the Nevada Medicaid Orthodontic Unit to determine the medical necessity of orthodontic treatment.
Q: Can Form FA-25 be used for other purposes?
A: No, Form FA-25 is specific to orthodontic medical necessity in Nevada and cannot be used for other purposes.
Form Details:
- Released on June 29, 2017;
- 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-25 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.
Download Form FA-25 Orthodontic Medical Necessity (Omn) Form - Nevada
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