Form FA-165 Lidoderm 5% Patches Prior Authorization Request Form - Nevada

What Is Form FA-165?

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:

• 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-165 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.