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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-65
for the current year.
Form FA-65 Synagis Authorization Request Form - Nevada
What Is Form FA-65?
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-65?
A: Form FA-65 is the Synagis Authorization Request Form in Nevada.
Q: What is Synagis?
A: Synagis is a medication used to prevent severe lower respiratory tract infections in infants.
Q: Who should use Form FA-65?
A: Form FA-65 should be used by healthcare providers in Nevada to request authorization for prescribing Synagis.
Q: What does Form FA-65 authorize?
A: Form FA-65 authorizes the prescription of Synagis for eligible infants.
Form Details:
- Released on October 13, 2020;
- 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-65 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.
Download Form FA-65 Synagis Authorization Request Form - Nevada
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