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Form FA-76 Prior Authorization Request - Cimzia (Certolizumab Pegol) - Nevada
What Is Form FA-76?
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-76?
A: Form FA-76 is a Prior Authorization Request form.
Q: What is Cimzia?
A: Cimzia is a medication that contains Certolizumab Pegol.
Q: What is Certolizumab Pegol?
A: Certolizumab Pegol is the active ingredient in Cimzia.
Q: What is a Prior Authorization Request?
A: A Prior Authorization Request is a form used to request approval from the insurance company for coverage of a specific medication or treatment.
Q: Why would I need to fill out Form FA-76?
A: You would need to fill out Form FA-76 if you are seeking prior authorization for Cimzia in Nevada.
Q: Who should fill out Form FA-76?
A: Form FA-76 should be filled out by the prescribing healthcare provider or their authorized representative.
Q: Is there a fee associated with Form FA-76?
A: No, there is no fee associated with filling out Form FA-76.
Form Details:
- Released on July 28, 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-76 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.
